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Pleasex1rit or type <br /> (Form designed for use on elite(12-pitch)"awnler) ; <br /> NON-HAZARDOUS t GeneratorUS EPA ID No Manifest Doc No 2 Page I's ' <br /> WASTE MANIFESTOf I <br /> 3 Ge7 <br /> ator's Name and Mailing Address t <br /> 1 V <br /> - r <br /> 4 Generator's Phone <br /> 5 Transporter 1 Comps Name 6 US EPA ID Number A Transporters Phone <br /> 7 Transporter 2 Company Name a US EPA ID Number B Transporter's Phone <br /> 9 Designated Facility Name and Site Address 10 US EPA ID Number C Facility's Phone <br /> 5 <br /> t r sr E { <br /> rw <br /> 11 ` ✓ ' <br /> Waste Shipping Name and Description 12 Containers 13 14 <br /> Total Unit <br /> " No Type Quantity Wt/Vol <br /> Kx <br /> G b <br /> E <br /> p�Y N r <br /> E <br /> R <br /> A c <br /> r>t` T <br /> O I� R d <br /> r <br /> I <br /> ` D Additional Descriptions for Materials Listed Above E Handling Codes for Wastes Lasted Above k <br /> 4 <br /> �+ I <br /> 15 Special Handling Instructions and Additional Information <br /> 16 GENERATOR'S CERTIFICATION I certify,the matenals described ahovo on this manifest are not subject to federal regulahorfr>for reporting proper disposal of Hazardous Waste fr <br /> Printed/Typed Name SignatureI <br /> Month Day Year <br /> T 17 Transporter 1 Acknowledgement of Receipt of Materials <br /> [ R <br /> N Printed/Typed Name Signature i f �f. Month Day Year <br /> S <br /> P <br /> O 16 Transporter 2 Acknowledgement of Receipt of Materials <br /> R <br /> T PrintedlTyped Name Signature Month Day Year <br /> E <br /> R <br /> 19 Discrepancy Indication Space <br /> r <br /> F <br /> A I <br /> G <br /> 1 <br /> L 20 Facility Owner or Operator-Certification of receipt of waste materials covered by this manifest except as noted in Item 19 <br /> 1 % <br /> T <br /> Y Printed/Typed Name Signature Month Day Year <br /> Printed by J J KELLER&ASSOCIATES INC <br /> Neenah WI 54$57-0MIS <br /> 12-BLS-05 Rei 12198 I <br /> GENERATOR'S COPY <br />