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1. Generator's US EPA 10 No. Marmot <br />ON -HAZARDOUS Document No. <br />2. Page 1 7 <br />0 <br />WASTE MANIFEST <br />3. Generator's Name and Mailing Address <br />4. Oneraior`sPhoria (IL <br />5. Transporter I Company Name <br />6. US EPA 10 Number <br />A. Transporters Phone <br />7. rransp®rI& 2 Company Name <br />6. US EFTA 16 Wumbir <br />B. Transporters Phone <br />9. Designated Facility Name and Site Adcln <br />kss 10. US EPA ID Number C. Facility's Phone <br />J,i <br />!I. Waste Shipping Name and Description <br />12. Tot14. <br />Containers <br />Total Unit <br />No. Type Quantity W(Noll. <br />a. <br />b. <br />E <br />N <br />E <br />R <br />A <br />0 <br />R <br />d. <br />D.Additional Description for Materials Lista <br />J Above <br />E. Handling Codes for West" Listed Above <br />15. Spedal Handling Instructions and Addil <br />one] Information <br />u <br />Q C' <br />16. GENERATOR'S CERTIFICATION: I Cel <br />tity, the materials described above on thispianilest are.not subject to federal regulations for reporting proper disposal of Hazardous Waste. <br />Month Day Year <br />PrintedrfteName <br />IN99ahtre <br />T f <br />A 17. Transporter I Ac"owledgement of Rec <br />31pt of Materials <br />N Printed/Type Name <br />Signeiure Month Day Year <br />S <br />P <br />018. splorter,2 Acknowledgement of Rec)lpt <br />of Materials <br />T Printecinype Name <br />Signature <br />E <br />19. Discrepeancy Indication 31.. <br />F <br />A <br />C <br />I <br />L 20. Facility Owner or Operator: Certification <br />of Receipt or red by IN$ manifest as noted In Item 19. <br />Y Printedirlype, Name <br />Signa. re j "Ih Day I Year <br />-7 ----F- <br />�_Wkw6ff,9 <br />Cbpy <br />