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NONwHAZARDOUS WASTE MANIFEST <br />Please mint or tvno (Form dasidnod for use an elite (12 pitch) typewriter) <br />NUN -HAZARDOUS 1. Generator's US EPA ID Ne. <br />WASTE MANIFEST-=' < f. 1 - t <br />3 Generator's Name and Mating Address <br />pm <br />a Generator's Phone ( r } { <br />5. Transporter 1 Company Name <br />7. Tmnsportar 2 Company Name <br />9. Dosignatrd Facilay Nance and Sita Address <br />8. US EPA ID Numbor <br />f�. l r f <br />B. US EPA ID Number <br />2 10. US EPA ID Mtmber <br />Maniiast <br />ant No. <br />A. State Transportar's ID '� <br />Q. Transported Phana . <br />C. Stato Transponet's ID <br />D. Tranripener2 Phone <br />F.. 5WI0 Facility's ID <br />F. Facility's Phone <br />i i 1. WA5TE DESCRIPTION � Cantainors 13. 1a. <br />7eta1 UrUt <br />No. Type Quantity Wt Not. <br />of <br />G� b <br />E <br />N <br />E <br />R c. <br />A <br />T <br />O <br />R d <br />G Additional Uascriptions far FAnlerials tJstad Abovo <br />t 5. Sperial dnndling Inslruclians and Additional Infarmauao <br />i <br />i - <br />AM <br />GENERATOR'S CERTIFICATION: 1 heratry certify That the contents <br />N. dandling Cados far Wastos Listed Above <br />ui this 5hiprnCol are (u'iY and accurately described and aro in a!I respncts <br />in proper condition for transport The materials described on this manifest are not subject to federal hazardous wasto regulations. <br />PrintediTypad Mame Signature <br />T 17. Transporter 1 Acknowledgement at Recaipt of Idatoriale <br />R <br />N Prirtledfiyped Name Signature <br />S {'. <br />P _ <br />O 18. Transporter 2 Acknowtadgeinenl of Receipt of Materials <br />R <br />T PrintwlTyped Name ASignature <br />E <br />R <br />F 18. Discrepancy Indication Space <br />A <br />C <br />L 20. Facifily Owner or Operator: Certification of receipt at the waste materials covered by this manffest, except as rioted in Item 19. <br />a_ <br />T Printedrl"ged Name Signature <br />Y <br />CFiQ 02002 LAF1fLMA5TERO (600)621-5808 vJanv.labelmaster.com <br />Dora <br />Month Day Yanr <br />® rn�.wn 4 raR,n <br />�M_uraixax �i50VINK} <br />Delo <br />Aforrlh <br />Day <br />Year <br />AAA <br />Date <br />Month <br />Day <br />Year <br />A. <br />Date <br />Alonth <br />Day <br />Year <br />Dora <br />Month Day Yanr <br />® rn�.wn 4 raR,n <br />�M_uraixax �i50VINK} <br />