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NON-HAZARDOUS WASTE MANIFEST <br /> Please print or type (Form designed for use on elite(12 pitch)typewriter) <br /> NON-HAZARDOUS 1.GeneratoisUSEPAIDNo, <br /> WASTE PJIANIFEST Manifest 2.Page I <br /> Document No. <br /> 3.Generator's Name and Mailing Addressof I <br /> C,i L)FO A t,11 A STC;p <br /> 4.Generator's Phone �.'T)16J <br /> S.Transporter 1 Company Name <br /> �t• 6. US EPA IDNumber <br /> ' <br /> {N� A.Stale Transport `s ID ! <br /> I �I <br /> B.Transporter)Phone <br /> 7.Transporter 2 Company Name 8. US EPA ID Number <br /> C.State Transporter's ID , <br /> D.Transporter 2 Phone <br /> 9.Designated Fap'Gty Name and Site Address 10, US EPA ID Number <br /> E.State Facility's ID ! <br /> MMU&"a i <br /> fft ` F.Family's Phone i <br /> t� <br /> 11.WASTE DESCRIPTION 12. Containers 13. 1A. <br /> Total Umt <br /> No. Type Quantity Wt.Nol. <br /> a. { <br /> I <br /> G b <br /> N <br /> E <br /> R <br /> A ! <br /> T i <br /> O <br /> R d. <br /> i <br /> G.Additional Descriptions for Materials Listed Above H.Handling Codes for Wastes Listed Above ' <br /> 1 <br /> rz�y! �o a L<f 1>�4�S /+.�v 0-D O� <br /> 1 <br /> 15.Special Handling Instructfens and Additional Information <br /> I <br /> {i <br /> 18.GENERATOR'S CERTIFICATION:I hereby certify that the contents of this shipment sre fully arta accurately described and are in all respects 1 <br /> in proper condition for transport The materials described on this manifest are net subject to federal'unzardous Waste regulations. <br /> Date ! <br /> Printed/Typed Name Signature Month Day Year <br /> c <br /> T 17.Transporter 1 Acknowledgement of Receipt of Materials .� Date <br /> A PrimedrrypedName SignatuManth Day Year j <br /> IN <br /> j 3 i <br /> 3 <br /> 44, <br /> p 18.Transporter 2 Acknowledgement of Receipt of Materials Date i <br /> R <br /> T Printed/Typed Name, Signature month Day Year <br /> E <br /> R ; <br /> t9.Discrepancy Indication Space <br /> ;F I <br /> A <br /> C f <br /> 20.Facility Owner or Operator Certification of receipt of the waste materials covered by this manifest,except as noted in item 19. ' <br /> fL Date <br /> LT Printed/Typed Name Signature y Month Day Year j <br /> Re,. 3/95 <br /> F-14 X2002 tABEII"IASTER® (800)621-5!308 www.Iabelmasteccom d <br /> 1l31L ! <br />