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• <br /> NON-HAZARDOUS WASTE MANIFEST <br /> Please print or type (Fom1 designed for am on elite(12 Pilch)typewtlter) <br /> NON-HAZARDOUS Generolora US EPA ID No. y /� `t'� 1{ <br /> WASTE MANIFEST kA "'"'1d5' {yq_.ti. 2.Pagei <br /> ffimmenl N . <br /> 3.Generator's Name arM Mailing tldz <br /> ress — CCY PI <br /> 4.GeneratorsP oh ne?(`�� ) 4t� <br /> 5,Transponer1 Company Name <br /> US EPA 10 Number <br /> Y e,2Compan Na'el-t•�-b'1C-�`- "1rk,tiLA1 r�,,,y'�� c` •�(( A.State Trareponera lD <br /> 7.Transporter 2 Company Name L 4W��J 4! b S.TPUMponer i Phone r'�s <br /> S• US EPA ID Number <br /> C.Slate TraMporteYs ID <br /> • 9.DesignatedFadlilp Name rid Site AdtlresS D.Tr <br /> asponer 2 Phone <br /> /' 10. US EPA 10 Number, <br /> x _Y�0 ii s t(�,(�(.k 6.1,. E.State Facility,10 <br /> ao:Na <br /> L ;',r C34rj > F.FaciliNa Phone } <br /> 11.WASTE DESCRIPTION -7(o'7 L47�5 <br /> 12. Cenminem 13. 14. <br /> Total Unit <br /> a, a <br /> No. Type Quantity WiNol. <br /> G e. <br /> E <br /> N <br /> • R p. <br /> A <br /> T <br /> O <br /> w R d. <br /> H <br /> G.Additional Descripllons lar Materials Usletl Above <br /> r � H.Handling Owns for Wastes Lienal Above <br /> n La ( 1 E )1 <br /> 15.Spedal Hentllirg Instmdions entl Atltlbional InformaUOn <br /> ^z <br /> D <br /> z <br /> . <br /> 16.GENERATOd,ion I TIFICATION:I nemby cenity Mat Ne coolants of(hls shlpmant are iWlyy and accurately tlesetl <br /> ID proper contl n for vasPon.The rstenals describetl on this mantlest ere no'subject to tetleral hazardous waste regulation,arin all respect <br /> As <br /> {�tQ_ ji1.l <br /> M]Pan I-� 7l rJ/..I <br /> Print:aMyped Nerve Dara <br /> '!A - iIAAJ r 9i nota /J <br /> rs�- � JAlone?oynal rD�aY Year <br /> T 17 TmnappdBr 1 Acknowletlgement of Receipt of Materials `- /� • J<v <br /> R <br />• A Pdnted/Typatl Nam. 041. <br /> 3 Siglnature <br /> Mone, Day year <br /> p 16.Transporter 2 Acknowledgement of <br /> R C/celpt of h5afedals ,/'' <br /> EPrinletl?y�tlName % 51 nature _ ! '' Dale <br /> R Mone, Day Year <br /> F 19.Discrepancy lndip(bn Space <br />• A <br /> C <br /> 1 <br /> L 20.Facility Owner or Operatpr;CeNOration al receipt of Me waste materials covered by leis manifest,esnpl as noted In Ram 18. <br /> T Printetl/Typetl Name <br /> y StgnptmData <br /> e <br /> feen <br /> F-14 02002 LASEAASTUO (1500)621-59pg www.labelmaaler.com �V <br /> rren, Rea 395 <br /> INK <br />