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NOW i WASTE MANIST <br /> Please print or type (Form designed for use on elite(12 pitch)typewriter)` _ <br /> L Generator's US EPA ED No. ^- +�' Manifest - 2.Page 1 ' <br /> NON-HAZARDOUS j Document No. f <br /> WASTE MANIFEST I'. r 01 f 4 <br /> 3.Generator's Name and Mailing Address_ s yt:.- y f•*y� „ f - - _ _ _ - S <br /> - 2 MIS' # t +..w,�C �,Jft✓a r* `- - _ _ - - ., _ <br /> + 4.Generator's Phone{ A— - V 0'ick. C41, <br /> Neiorter 1 Company NameB. US EPA ID NumberA.State Transporter's ID VAJ dIt 7` Asrs• U �� 774-A-1 B.Transporter 1 Phone 2ji f•� �� 7� <br /> 7,Transporter 222 Company Name ` 'i 8. US EPA 10 Number C-State Transporter's ID <br /> _ IR D.Transporter 2 Phone - <br /> 9.Designated Facility Name and Site Address - i` ii 10. US EPA ID Number E State Facility's!D i <br /> o po er&NJt?o o me A*0- L 1 <br /> —7V 15ft?09-T3/ ij �Y�J•� (� F.Faci[ityy'ss Phone 1 T II <br /> - <br /> 1i.WASTEDE$CRIPTION'" �rrl%-���-�„.s.'•-��rwr= -s., �,, <br /> 14. <br /> Tr <br /> 12. Containers 13. <br /> Total -Unit <br /> l y No. Type Quantity Wt./Vol.-Z�,E / 4 <br /> G <br /> N �f <br /> F <br /> R c <br /> mow,•„t;-. � rt, �.�.�_^ I� �i _ _.. - - - ,�T:- ..� - .--- _ <br /> if <br /> q d I} II <br /> W <br /> N <br /> f Q G.Additional Descriptions for Materlals Listed Above !C 'j- H.Handling Codes for Wastes Listed Above <br /> 1 $ j <br /> Q15.Special Handling Instructions and Additional Information <br /> i <br /> O <br /> �J <br /> L � I <br /> 76.GENERATOR'S CERTIFICATION:I hereby certify that the contents of this shipment are fully and accurately described and are in all respects <br /> C <br /> proper condition for transport.The materials described on this manifest are not subject to federal hazardous waste regufationsdf <br /> - <br /> �'. v' Dale <br /> Printedflyped Name :n ; Signature SFr Month Day <br /> Year <br /> r- <br /> T 17.Transporter 1 Acknowledgement of Receipt of Materials Date ' <br /> R <br /> A Printedlfyped Name �� Signature �' f _ ”' �� "--,Month Day Year <br /> N f <br /> "S {��# ,.r g � .� e•t ; s v- '� � .r_�..! tit-.---- /f----•""---w—"—'" - � � <br /> 'br 18.Transporter 2 Acknowledgement of Receipt of Materials Date <br /> R Printedl7yped Name Signature . Month Day Year <br /> E "i y <br /> R <br /> I <br /> 19.Discrepancy Indication Space <br /> F <br /> C k <br /> I 2o.Facility Owner or Operator;Certification of receipt of the waste materials covered by this manifest,except as noted in item 19. - <br /> �� '! Date <br /> '{ Ppgtedfgi Name - ; I� Signature Month Da Year <br /> ly <br /> • Rev. t <br /> F-14®2002 LASELMASTER� (800)621-5808 www.labelmaster.cd <br /> m !I r� 3195 . <br /> ' 't SOY INK <br />