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pVJ- �'Is <br />NON-HAZAFiDOU <br />2. Page 1 <br />1. Generators US EPA ID No. Manifest <br />WASTE MANIFES <br />DocumentNo. <br />J <br />of 096213 <br />3.1Ggnerators N me an Mailing dre <br />(CC' Ati <br />aU <br />V(j�ic� c�r1 <br />A <br />t <br />Ghl0 n C`\ 1 KS204- <br />4. Generator's Phone <br />5. Transporter 1 Company Name <br />6. US EPA ID Number <br />A. Transporters Phone <br />1.,2G <br />7. Transporter 2 Company Name <br />8. US EPA ID Number <br />B. Transporters Phone <br />9. Desi nated Facigand Sit Add <br />C�o�Cr NaMnJnlzI ln <br />ss 10. US EPA ID Number <br />ArY'i I <br />C. Facility's Phone <br />31$52 C. CovR y <br />12 S7. <br />Cq2�� �$� 3? "r7 <br />\Air--LL:1-0Af <br />N? <br />11. Waste Shipping Name and Description <br />12. Containers <br />13. <br />14. <br />Total <br />Unit <br />No. Type <br />Quantity <br />WWol <br />a. NOM k"k00US <br />WAS1t� 5DL1�-D <br />� <br />C <br />G <br />b. <br />E <br />N <br />E <br />R <br />C. <br />A <br />T <br />O <br />R <br />d. <br />D. Additional Description for MaterialsList <br />Above <br />E. Handling Codes for Wastes Listed Above <br />(vs al FlIle <br />H/3 �- <br />15. Special Handling Instructions and Addi <br />Tonal Information <br />1 p <br />I S`(25 S <br />16. GENERATOR'S CERTIFICATION: I Cei <br />lity the materials described above on this manifest a subj t to fecl-.r,4146ulations (or repor ' per disposal of Hazardous Waste. <br />Printed/Type Name- <br />Signal <br />�,V <br />Month Day <br />Year <br />T <br />cx.S q10 , <br />t O <br />0. <br />1. i <br />R <br />A <br />17. Transporter 1 Acknowledgement of Rec <br />Opt of Materials <br />N <br />S <br />Printed/Type Name <br />Signature <br />Month Day <br />Year <br />P <br />51— <br />O <br />R <br />18. Transporter 2 Acknowledgement of Receipt <br />of Materials <br />T <br />Printed/Type Name <br />Signature <br />Month Day <br />Year <br />E <br />R <br />19. Discrepeancy Indication Space <br />F <br />A <br />C <br />I <br />1 I <br />' 20. Facility Owner or Operator: Certification <br />of Receipt or waste materials covered by this manifest as noted <br />in Item 19. <br />T <br />Y <br />Printed/Type Name <br />)Signature <br />q/ <br />Month Day <br />Year <br />— q. - . - - / / r- <br />d "'.? <br />-6 <br />ORIGINAL RETURN TO GENERATOR <br />