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NOWHAZARDDUI WASTE MANIFEST <br /> Manse print or type (Form designed for use on elite(12 pitch)typewnter) k- k f 1 <br /> NON-HAZARDOUS 1.Generators US EPA ID No Mantles!Docuz_Page 1 <br /> ment No. <br /> WASTE MANIFEST (A <br /> 3.Generators NarM and Melling Address <br /> I <br /> 4.GAIlerators Phone( 1 <br /> S.Transporter 1 Company Mama &. US EPA ID Number A.Slate Transporters ID <br /> 8,Transporter 1 Phone <br /> 7.Transporter 2 Company Name 8. US EPA ID Number C.State Transporters ID . <br /> D.Tran5porler2 Phone <br /> 9.Designated Facility Name and Sita Address 10. US EPA ID Number E,Stale Facitily's ID <br /> t F.facility's Phone <br /> t f.WASTE DESCRIPTION 12. Containers 1 14. 4 <br /> Total Unit <br /> No. TYPO Quantity 4 <br /> .1vol. <br /> a ! <br /> G b. <br /> E <br /> N i <br /> E <br /> R c. <br /> A i <br /> T <br /> O <br /> WIN <br /> R a <br /> H <br /> N <br /> 3 G.Additional Descriptions for Materials Listed Above H.Handling Codes Ior Wastes Listed Above <br /> V} <br /> 0 <br /> Q15.Special Handling Inapuctfom and Additional Information <br /> _ <br /> Z <br /> 0 -,- <br /> Z <br /> 15.GENERATOR'S CERTIFICATION:I hereby certify that the Wntents of this shipment are Uly and acearatety deSentied and are In aN map" <br /> In proper condition Ior transport,Tho matenots described on this martilesl are not sub)ec1 to federal hazardous waste regulations. <br /> Date <br /> Prtnred/Typed Name Signature Month Day Year <br /> f <br /> T t7.Transporter 1 Acknowledgement of Receipt of Malerials Date <br /> R <br /> PrintwliTyped Name Signature Month Day Year <br /> S t <br /> 0 18.Transporter 2 AcknoWedgement ob Receipt of Materials Oats <br /> T PrintedlTyped Name Signature Monts Day Year <br /> E <br /> R <br /> 19.Discrepancy Indication Spare <br /> F <br /> A <br /> C <br /> ( 20.Faciftp Owner or Operator:Certification of receipt of the waste materials Covered by this manifest,except as noted in item 19. <br /> L Date <br /> T rPrintedlTypod Name Signature Month, Day veer <br /> f. . i r <br /> Y �� r � f I 'k-1 <br /> CF14 VON LAiJ.PLAFMO 1500)821-58ae rmw.labstmasrer_wn W '9"B��'x+• wpmmw <br />