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NON-HAZARDOUS 1.Generator's S EPA ID No. 2.Page 1 3.Document Number <br /> of <br /> WASTE MANIFEST NH-N° 21 73 <br /> 4.Generator's Name and Mailing Address <br /> 2-1-4(z L..,I,4�- <br /> Generator's Phone <br /> 5.Transporter Company Name 6. US EPA ID Number 7.Transporter Phone <br /> �i ar����_� V. v+✓l G,hCr ae,�¢p t� "Z Q (3 � ���O ._ �.LL cY of „ � �+7 <br /> B.Designated Facility Name and Site Address 9. US EPA ID Number ib.Facility's Phone <br /> �- <br /> r: 9 7 et(� <br /> E 11.Waste Shipping Name and Description 12.Containers 13. ta. <br /> N Total Unit <br /> E No. Type Quantity W1Ncl <br /> R a. <br /> A �} <br /> O <br /> b. <br /> 15.Special Handling Instructions and Additional Information Handling Codes for Wastes Listed Above <br /> 11 a. 11b. <br /> 16.GENERATOR'S CERTIFICATION: I certify the materials described above on this manifest are not subject to state or federal regulations for reporting proper disposal of Hazardous Waste. <br /> PrintedlTyped Name Signature <br /> MonthDay YeaRir <br /> ! <br /> S 17.Transporter Acknowl&clgernant of Receipt of Materials <br /> P <br /> O Printed/Typed Name Signature <br /> R <br /> T 4 � Month Day Year <br /> E <br /> R <br /> 18.Discrepancy Indication Space <br /> F <br /> A <br /> C <br /> I <br /> L <br /> I <br /> T <br /> Y 19.Facility Owner or Operator.Certification of receipt of waste materials covered by this manifest q9cept as#bted in Item 18. <br /> Printed/Typed Name Signature <br /> Month Day Year <br /> WHITE—ORIGINAL(Return to Generator) YELLOW—TSDF(Retain Copy) PINK—TRANSPTER COPY GOLDENROD—GENERATOR'S COPY <br />