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4 to <br />WASTE MANIF19T <br />�Fi *8se print or type (Form designed for use on elite (12 pitch) typewriter) <br />1. Generator's US EPA ID No. <br />qqQryrpp ppIQ.1­1 <br />3. Generator's Name and Mailing Address <br />N73 NOM WSAI Leon <br />4. Generaor s Phone ( i <br />5. Transporter 1 Company Name <br />dwrsewj cheradmi ` d tet:.' °t <br />7. Transporter 2 Company Name <br />9. Designated Facility Name and Site Address <br />' ;8 F ANe <br />11. WASTE DESCRIPTION <br />G. Additional Descriptions for Materials Listed Above <br />15. Special Handling Instructions and Additional Information <br />Manifest <br />Document No. <br />2. Page 1 <br />Of <br />6. US EPA ID Number A. State Transporter's ID <br />Vk R,0040'705sj B. Transporter 1 Phone <br />8. US EPA ID Number C. State Transporter's ID <br />D. Transporter 2 Phone <br />10. US EPA ID Number E. State Facility's ID <br />F. Facility's Phone <br />24 - t 2 2 <br />Containers 13. 14. <br />Total Unit <br />No. Type Quantity WIJVGI. <br />IX k <br />H. Handling Codes for Wastes Listed Above <br />16. GENERATOR'S CERTIFICATION: I ==the that the contents of this shipment are fully and accurately described and are in all respects <br />in proper condition for transport. The matenals described on this manifest are not subject to federal hazardous waste regulations. <br />Printrl/Typ ` Name Signature <br />T17. <br />Transporter 1 Acknowledgement of Receipt of Materials r. e <br />R <br />A <br />N <br />Pnntedrryped Name 4( <br />Signature <br />Year <br />P <br />O <br />18. Transporter 2 Acknowledgement of Receipt of Materials <br />R <br />T <br />Printed/Typed Name <br />Signature <br />E <br />Month <br />R <br />Year <br />F <br />19. Discrepancy Indication Space <br />An <br />C <br />L20. <br />Facility Owner or Operator: Certification of receipt of the waste materials covered by this manifest, except as noted in item 19. <br />Month <br />Day <br />Year <br />Printed/ryped Name <br />Signature <br />Date <br />Month Day Year <br />CF14 0 2002 LABEI.I`e'IASTER® (800) 621-5808 www.labelmaster.com°YwRWINQ <br />Date <br />Month <br />Day <br />Year <br />Date <br />Month <br />Day <br />Year <br />Date <br />Month <br />Day <br />Year <br />Date <br />Month Day Year <br />CF14 0 2002 LABEI.I`e'IASTER® (800) 621-5808 www.labelmaster.com°YwRWINQ <br />