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4. L,0.0.00*3VL <br /> enerator's U E No. Manifest 2. Page I a w <br /> ` NON-HAZARDOUS Document o <br /> WASTE MANIFEST 4• o.o-�•o• °f 7�*j2• <br /> 3. Generator's Name and an �ress11 <br /> A. Generators Phone JoISPI--S 500 4'S <br /> 5. Transporter 1 Company Name 5. US EPA ID Number <br /> A- e.A.v•00-01.4.'(P.03.1 <br /> 7. Transporter 2 Company Name B. US EPA ID Number <br /> ` 9: Designated Facil' Name and Site Address 10. US EPA ID Number A. Transporter's Phone j Z3fj EZj <br /> B. Transporters Phone <br /> C. Facility's Phone <br /> DoD G,.1c-r °1 �r�lvj G A.v.o. 4. D. fad-�� <br /> 12. Containers 13. 14. <br /> 11. Waste Shipping Name and Description Total Unit <br /> No. Type Quantity Wt Vol <br /> a. <br /> OA <br /> G b. <br /> t E <br /> N <br /> E <br /> R <br /> A c. <br /> T <br /> D <br /> R <br /> cl <br /> 0. Addiiionaf Descriptions for Materials Listed Above E. Handling Codes for Wastes Listed Above j <br /> r <br /> f <br /> 15. Special Handling instructions and Additional Information I_ <br /> i <br /> t <br /> i <br /> lb.GENERATOR'S CERTIFICATION: l certify the .na+erials descnaea above an this rnonlfest are not subiea r0- federal regubdpns for reporting cruor disl3osal of Hn2ordovs Waste. I <br /> Prinied/Typed Name Signofure., -'rte Month Doy Year <br /> ' T 17.Transporter 1 Acknowiedoemeni of Receipt of Materials t <br /> R ' <br /> A Printed/Typed Name f Signature �:% Month Day yeaN Itr <br /> S <br /> p18.Transporter 2 Acknowledgement of Receipt of Materials <br /> R <br /> T Printed/Typed Name Signature Month Day Year <br /> E <br /> R <br /> 19.Discrepancy indication Space <br /> F <br /> w <br /> 20.Facility Owner or Operator Certification of receipt of waste materials covered by this manifest except as noted in Mem 19. <br /> T <br /> Y Printed/Typed Name Signature Month 9" . Year, <br /> •-+ii� ::-nYgc <br /> I <br /> GENERATOR'S COPY <br />