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, r <br /> N4tWHAZARDOUS WASTE MANR40-ST <br /> Please point or type 4(Form designed for use on elite(12 pitch)typewri€er) <br /> Manifest E2. e 1 <br /> N77N-HAZAR©OUS 1.Generators US EPA ID No- DocumentWASTE MANIFEST <br /> 3.Genemlofs Name and Mailing Address I <br /> ( �west Ew <br /> 13 SCS <br /> 4.Generator's Peons <br /> S.Transporter,Company Name 8_ US EPA 0 Number A.State Transporter's fD <br /> " T � B.Transporter 1 Phone <br /> 7 Trarlsport r 2C Name a_ US EPA ID Number C.Stale Transporter's ID <br /> °�;+'"1'�.b? D.Transporter 2 Phone <br /> 9-Designated Facility Name and Site Address 10, US EPA ID Number F.State Facility's 10 <br /> I. C A&MMF.Facility's Phone <br /> FO S <br /> 11.WASTE DESCRIPTION 12. Caltainers 13. 14. <br /> Total Unit <br /> No, Type Quantity Wt.1Vol. <br /> a. <br /> G b. <br /> E <br /> N <br /> E <br /> R c. <br /> A <br /> T <br /> O <br /> 11 <br /> R d. <br /> n <br /> G.Additional Descriptions forMateriais Listed Ahme H.Handling Codes for Wastes IJsted Above <br /> 7 <br /> } <br /> t Lir 1.7- �T k�J >Q <br /> r <br /> 15-Special Handling Instructions and AderTonat lntormation <br /> w <br /> 16.GENef3ATOt3'S CERTIFICATION:I hereby certify that the contents of this shipment are fullyy and accurately described and are in all respects <br /> in proper condition for transport.The materials described on this manifest are not subject to iederat hazardous waste regUlationS. <br /> Gate <br /> Printedffyped Name Signature hionth airy Year <br /> T 17.Transporter t AcknowlecIgement of Receipt of Materials Dale <br /> R )) J@ j <br /> s P�- --� �[ Signa,u ,� r� �nZ � r <br /> („fi <br /> P � <br /> 0 18.Transporter 2 Acknowledgement Of Receipt of Matenals Date <br /> R PrintedrTyped Name Signatum Month flay Year <br /> E <br /> R <br /> 19.Olscrepancy Indication Space <br /> F <br /> A <br /> C <br /> 24,Facility Owner or Operator;Certification of receipt of the waste materials covered by this manifest,except as noted in item 19, <br /> Date <br /> T Printed Typed Name Signalure4$ Month pay Year <br /> r_t <br /> lyl <br /> f <br /> F-1402D02 LAKAASTER0 (8)0)621-5868 wxW.labelmasie;:com xr�: Rev. 3+95 <br /> SOY Miff(_ <br />