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NONwHAZARDOUS WASTE MANIFEST <br />Please print or type (Form designed far use on elite (12 pitch} typewriter) <br />CF14 02002 LA9ELMASTFJ2® (800) 621-5868 ww <br />NON-HAZARDOUSa}o15J_ftEPyiED.N <br />Manifest t <br />2, <br />Page 1 <br />s <br />s <br />Document No, <br />WASTE MANIFEST <br />., <br />"`tp <br />of <br />VG 1Irp�Ir MWRd Mailing Address <br />'ij ".••yFtz�ac`I-,r^`F.£7yt ir:-.i.4aE <br />.. <br />POPP <br />4. Generator's Phone <br />5 Tr nsportq {{yy Cop�rt•f� 1ny1Js,f11a:-,,,. ( >, 0. <br />US EPA ID Number) jt( f•'i6@ :. dF <br />�. r.x <br />A, State Transporter's ID <br />.. <br />.. .. .. <br />... <br />f9T>;Ikj.i3�iS L8€C`YtE�s,..+;'4Y 333i�.1`K4E �': <br />...I _. <br />H. Transporter 1 Phone <br />4eiT^`!'1t <br />$'e <br />bim <br />7. Transporter 2 Company Name 8. <br />US EPA ID Number <br />C. State Tmnspartar's ID <br />D. Transporter 2 Phone <br />9 Ignat�ef Facility aS7re end Shp Address 10, <br />- <br />US EPA ID Number <br />E. State Facility's ID v.`^, €ik.l $ A)Q1 <br />:. <br />iF iF-. 7vf'3t$:LeES <br />.'+J <br />��;;�-�;rrs, � ads ;'•�?;�«� <br />F. Facility's Phone <br />11. WASTE DESCRIPTION <br />Containers <br />13. <br />14, <br />Total <br />Unit <br />No. <br />Type <br />Quantity <br />Wt.Nol. <br />tt '} <br />L�-:�% < >E a^ ;i,f 3 �': T -'f <br />�+ <br />b. <br />E <br />N <br />E <br />R <br />c. <br />A <br />T <br />0 <br />R <br />d. <br />G. Additional Descriptions for Materials Listed Above <br />H. Handling Codes for Wastes Listed <br />Above <br />tt <br />r,.'� <br />P d F d x`,?:' :3 Eik1t <br />`�Y� j'kisf%�F <br />15. Spada( Handling istructions and Additional Information v a <br />lilt GENERATOR'S CERTIFICATION: f hereby cattily that the contents of this shipment <br />are fully and accurately described and are in <br />all respects <br />in proper condition for transport. The materials described on this manifest are not subject to federal hazardous waste regulations. <br />Printedttyped Name ;.'' <br />Signature <br />,Month <br />'Day <br />Year ' <br />TT <br />17. Transporter 1 Acknowledgement of Receipt of Materials <br />Date <br />A <br />Prfoted/Typed Name t <br />Sigr at�re — ' f <br />s <br />Month <br />Day <br />Year <br />N_ <br />9Y,r<T <br />i <br />P <br />0 <br />tat Transporter 2 Acknowledgement of Receipt of Materials <br />Date <br />R <br />T <br />Printed/Typed Name <br />Signature <br />Month <br />Day <br />Year <br />E <br />R <br />19, Discrepancy Indication Space <br />F <br />A <br />C <br />1 <br />20. Facifity Owner or Operator Certification at receipt of the waste materials covered by <br />this manifest, except as noted in Item 19. <br />Data <br />T <br />PrintedYtypedNameSignature <br />R,bnth <br />Day <br />Year <br />Y <br />w.labehnaster.cam <br />arc m �ei»�-.rvnw a,m�� <br />