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SON-HAZARDOUS WASTE iVr4NIFEST <br /> Please print or type (Form designed for use on elite(12 pitch)typewriter) <br /> NON-HAZARDOUS 11.Genes Wt Us EPA iD No. Manifest <br /> • WASTE MANIFEST Document No. 2-Page 1 <br /> 3,Generator's Name and Matting Address y of f <br /> 4.Generator's Phone( ) (C K T P•t <br /> 5.Transponer t Company Name <br /> 6• US EPA ID Number er A State Transporter's ID <br /> I i J_i�A-1 1 <br /> 7.Transporter 2 Company Name B.Transporter 1 Phone <br /> II. US EPA ID Number C.State Transporters ID <br /> D.Transporter Phone <br /> 9.Designated Facility Name and Site Address t0, US EPA ID Number <br /> r+ C'z E State Facility's 1D <br /> A L�d• <br /> R!O A, F.FaaVty's Pion _ <br /> I 1.WASTE DESCRIPTION <br /> #V)v t: <br /> 12. Containers 13. I14. <br /> Total <br /> a. Na. Type Ouantity WLIVOL <br /> G b• <br /> E <br /> N <br /> E <br /> R C- <br /> A <br /> T <br /> 0 <br /> R d. <br /> G.Additional Descriptions for Materials Usted Above <br /> H-Handling Codes for Wastes Usled Above <br /> 1S.Special Handting Instructions and Additional Information <br /> I <br /> 16.GENERATOR'$CERTIFICATION-I hereby certify that the contents of this shipment are fully and gc ratery described and are in all respects <br /> In proper condition for transpon.The materials described on this manifest are notsubject to ederal hazardous waste regulations. <br /> Printod/t <br /> Y!>ed Name Signature Data <br /> March Day Year <br /> RT 17.Transporter t Acknowledgement of Receipt of Materials <br /> 4 PrintedlTyped Name Date <br /> Y Signature <br /> i t t ti 'i r rr f: - ✓ Month Day Year <br /> nsponer 2 Ackiiouledgement of Receipt of Materials <br /> Printed/Typed Name Date <br /> Signature i <br /> Monfh Day Year J <br /> 19.Discrepancy Indication Space <br /> I <br /> 20.Fac+Tdy Owner or Operator;Certification of receipt at the waste materials covered by this manifest.except as noted in item 19: <br /> Printedlryped Name <br /> 1 Signature Date <br /> Month Day Year <br /> ( s. J + <br /> t <br /> 14 192002 LA6ELMASSt:R® (etw)62l-5808 wmv.labetmastermm i <br /> Rev.3r95 E <br />