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t - <br />2. Page 1 <br />NON-HAZARDOU <br />1. Generator's Us EPA ID No. Manifest <br />WASTE MANIFES <br />Document No. <br />of <br />c. �.� <br />3. Gensrator4.Nsme and Malling Add <br />V l <br />f <br />'A 1 f_ F: • i t t :.l <br />4D: i.r - <br />.3 i t ' <br />�i •.- { •c.: 't..c1.1 t �V 1'. <br />�(i: � � '.. .. `}:1 -F� � ':J fr. <br />4.nerators Phone {.•' <br />5. Transporter 1 Company Name <br />S. US EPA ID Number <br />A. Transportees Phone <br />1 /. <br />7. Transporter 2 Company Name <br />8. US EPA ID Number <br />B: Ttansporteei Phone <br />9. Dgsignated Facility Name and Site Addr <br />3ss 10. US EPA ID Number <br />C. Facility's Phone <br />r{i` 1 moi: �rvC - _ <br />lite j'r JV.i 11 4i <br />11. Waste Shipping Name and Description <br />12. Containers <br />13. <br />14. <br />Total <br />Unit <br />� i• � r j ;+•.' f. i : t : fes. 4 )1 t <br />f - iii ` (t. _? ` <br />No.TWO <br />Quantity <br />WWol <br />a. <br />G <br />E <br />E <br />C- <br />- - <br />R <br />A <br />T <br />O <br />R <br />d. <br />D. Additional Description for Materials Liste <br />Above <br />E. Handling Codes for Wastes Listed Above <br />15, Special Handling Instructions and Additil <br />Dnal Information <br />ti' ia. <br />�f:f '! 1_- �;_=ti �l :i.l .?i i�'lf ?'S '' •��::�'I'i:'«�}'.fif+. t: :1)s. ..-r-;T` <br />18. GENERATOR'S CERTIFICATION: I Car <br />fy the materials described above on this manifest are not aubjeot to lederal regulations for reporting proper disposal of Hazardous Waste. <br />PrintadrType Name f.% s.: `. i f ; <br />^ ` i t t , �':. Signature Month Day Year <br />T <br />Y; it=.'ci �. t -I: r'. ';f: t.'. - <br />:. c• .. _.__ <br />A17. <br />Transporter i Acknowledgement of Recc <br />Ipt of Materials <br />N <br />Printedrrype Name <br />S"M Month Day Year <br />O <br />R <br />18.'Transporler 2 AdcnovAedgement of Re <br />pt of Materials - <br />Printedrrype Name ` <br />— <br />Month Day Year <br />T <br />E <br />R <br />18. Discrepeancy Indication Space <br />F <br />A <br />C <br />t <br />1 <br />20. Facility Owner or Operator: CartIfici <br />tion of Receipt or waste materials covered by this manifest as noted In Item 19. <br />T <br />Y <br />Printed/Type Name <br />t, • t Month rF)a 1 Year <br />Signature 1y <br />OFNERATOR'S CORY <br />i <br />