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c r'K4� r � <br />Rfnted by J. J. KELLER a ASSOCIATES, INC. 12 -BLS -05 Rev: 1/97 <br />GENERATOR'S COPY <br />NON -HAZARDOUS <br />1. Generator's US EPA ID No. Manifest <br />2. Page 1 <br />WASTE MANIFEST <br />Document o. <br />of <br />3. Geferator's Name and Mailing Address <br />4. Generator's Phone <br />5. Transporter 1 Company Name <br />6. US EPA ID Number <br />A. Transporters Phone <br />tir <br />7. Transporter 2 Company Name <br />8. US EPA ID Number <br />B. Transporter's Phone <br />9. Designated Facility Name and Site Address <br />10. US EPA ID Number <br />C. Facility's Phone <br />ALTAMOW WORI <br />I OW ALTANIONT PASS M. <br />; ___- <br />LtYE CA 9455010 <br />A .&.8.1.3.8.2.7.3. 2, <br />404494530 <br />11. Waste Shipping Name and Description <br />12. Containers <br />13. <br />14. <br />A� = <br />No. Type <br />Total <br />Quantity <br />Unit <br />WtIvoi E <br />4J/' <br />.:�!'./ <br />G <br />b. <br />E <br />N <br />E <br />R <br />A <br />c. <br />T <br />O <br />R <br />d. <br />D. Additional Descriptions for Materials Listed Above <br />E. Handling Codes for Wastes Listed Above <br />15. Special Handling Instructions and Additional Information <br />• l til <br />PR0F*.E#.__ <br />CUs E <br />t� <br />-16: GENERATOR'S CERTIFICATION: I certity the materials described above on this manifest are not subject to federal regulations for reporting proper disposal of Hazardous Waste. <br />Printed(Typed Name <br />Signature / , // <br />Month Day <br />Year <br />TR <br />17- Transporter 1 Acknowledgement of Receipt of Materials <br />A <br />Printed/Typed Name <br />Signature " <br />Month Day <br />OR <br />18. Transporter 2 Acknowledgement of Receipt of Materials <br />EPrinted/Typed <br />Name <br />Signature <br />Month Day <br />Year <br />R <br />r <br />19. Discrepancy Indication Space <br />x <br />F <br />A <br />C <br />L <br />20. Facility Owner or Operator. Certification of receipt of waste materials covered by this manifest except as noted in Item 19. <br />= <br />Printed/Typed Name <br />Signature <br />Month Day <br />Year <br />Rfnted by J. J. KELLER a ASSOCIATES, INC. 12 -BLS -05 Rev: 1/97 <br />GENERATOR'S COPY <br />