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tOrt'elite(12-pRch}typermter� n � � f�_'`'�.`�# <br /> NON-HAZARDOUS 1. Generator's US EPA ID No. Manifest Doc.No. 2. Pagel <br /> WASTE MANIFESTtit of <br /> enerator'sN=Tcling Address <br /> 4. Generator's Phone( � � <br /> 5. porterr 6. US EPA ID Number A. Tran e s Ph e <br /> r. <br /> 7. Transporter 2 Company Name 8. US EPA ID Number B. Transporters Phone <br /> 9. Qesignated Facility Name and Pite Address 10. US EPA ID Number C. Facility's Phone <br /> 11.Waste Shipping Name and Description 12. ContainersAQuantity <br /> - <br /> a �` ` No. Type r=. <br /> G leeki 2x), 1 <br /> G b. <br /> E <br /> E <br /> R <br /> A c. '~f <br /> e T ;: <br /> O <br /> R <br /> I d. <br /> ditionall criptions f aterials Listed Above E. Handling Codes for Wastes Listed Above <br /> a <br /> f <br /> 15.Special Handling Instructions and Additional Information <br /> f' <br /> 16.GENERATOR'S CERTIFICATION: 1 certify the materials described above on this manifest are not ct to federa re ulations for re ortin <br /> 9 p g proper disposal of Hazardous Waste. <br /> yped N me gn ur <br /> _ M nth Day Year <br /> e <br /> R 17.Transporter Acknowledgement of Receipt of Materials <br /> N Pn''p ed/Typgd Name Signatur <br /> S C��//�Q ff�z y ) L y ,� y Month Day Year <br /> P r `�P`� <br /> R 18.Transporter 2 Acknowledgement of Receipt of Materials <br /> E Printed/Typed Name Signature <br /> R Month Day Year <br /> 19.Discrepancy Indication Space <br /> F <br /> A r?. <br /> C <br /> I <br /> I Facility Owner or Operator:Certification of receipt of waste materials covered by this manifest except as noted in Item 19. <br /> Y <br /> Printed/Typed Name Signature <br /> Month Day Year t <br /> Printed 6Y f 1 ICEL LER 8 ASSOCIATES INQ � ' ss <br /> Neenah WI 54957-0368 <br /> GENERATORS COPY �` .12 BLS G5'Rev. 12/98 I <br />