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Please print or <br />°,;. <br />GrAELUM Cc" <br />NON -HAZARDOUS 1. Generator's US EPA ID No. Manifest o j <br />oc <br />2. Page 1 <br />% <br />WASTE MANIFEST <br />of <br />3. GenerfQ7't Nome and Maili g Address <br />4. Generator's Phone (?/�, ) 2,(9 <br />5. Transporter 1 Company Name/ 6. US EPA ID Number <br />A 91 <br />J7 <br />e <br />7. Transporter 2 Company Name 8. US EPA ID Number <br />. <br />9. Dgsignoted Fgcility NomeSitg Ad ss 10. US EPA ID Number <br />A. Transporter's Phon <br />rd <br />///I/� <br />B. Transporters Phone <br />C. Facility's Phone <br />/t/� <br />11. Waste Shipping Name and Description <br />12. Containers <br />13. <br />Total <br />14. <br />Unit <br />No. I Type <br />Quantity <br />Wt Vol <br />a. <br />G <br />b. <br />E <br />N <br />E <br />R <br />A <br />T <br />c. <br />O <br />R <br />d. <br />D. Additional Descriptions for Materials listed Above <br />E. Handling Codes for Wastes Listed Above <br />15. Special Handling Instructions and Additiggal Information r <br />fI �! y , - f /�. f� ., ...•. °`° d- ! "ice <br />r ..., F, <br />16. GENERATOR'S CERTIFICATION: I certify the materials described above on t are su tect to federal regulations for reporting proper disposal of Hazardous Waste. <br />Printed/Ty{lped Namegpafure <br />/� , <br />Year <br />Month Do Year <br />T <br />17. Transporter 1 Acknowledgement of Receipt of Materials <br />R <br />A <br />Pn d/Typed Name Signoturg j <br />Month Day Ye or <br />p18. <br />Transporter 2 Acknowledgement of Receipt of Materials <br />R <br />T• <br />Printed/Typed Nome <br />$igrroture <br />Month Day Year <br />E <br />R <br />19. Discrepancy Indication Space <br />F <br />A <br />C <br />I <br />L <br />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 <br />Printed/Typed Nome Signature <br />Month Day Year <br />GrAELUM Cc" <br />