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NON- HAZARDOUS WASTE MANIFEST <br />Please print or tvcr (Form lesioned for use on elite (12 Ditch) tvpowdter) <br />F•14 J2002 LABF.LMASTEBm (800) <br />NON -HAZARDOUS <br />1_ Ganarators US EFA ID No. <br />Manifest <br />2. <br />Page 1 <br />Document No ;= z. e' <br />^"? <br />WASTE MANIFEST <br />< :.�, � <br />of <br />3. Generators Name and Mailing Address <br />ii ?i" - •.`rib._. <br />.._ ., ,_..; �s <br />4. Gonerator's Phone ( Y=1'r <br />5. Transporter 1 Company Name 6, <br />US EPA ID Number <br />A. State Transporters 10 <br />.s,:•:,.tr, :{. .{"T'; _, <br />B, Transporter l Phone4 <br />4 <br />7 Transporter 2 Company Name 8. <br />US EPA ID Number <br />C. State Transporters ID <br />D. Transporter 2 Phone <br />T Designated Facility Name and Site Address 10, <br />US EPA 10 Number <br />E. Slate Facility's ID <br />' <br />F. Facility's Phone <br />4- <br />11. WASTE DESCRIPTION <br />12. Containers <br />13. <br />14. <br />Total <br />Unit <br />No, <br />Type <br />Quantity <br />Wt -Nal. <br />a. <br />G <br />b. <br />E <br />N <br />E <br />R <br />p. <br />A <br />T <br />a <br />R <br />d. <br />G. Additional Descriptions for Materials Listed Above <br />H. Handling Codes for Wastes Listed Above <br />15. Special Handling Instructions and Additional iniormalion <br />WAFAVAUAWAFAFAWAFAVAKAWAIVAMMYAWjWAWM <br />16. GENERATOR'S CERTIFICATION: i hereby cattily that the contents of this shipment are fully and accurately described and are in <br />all respucts <br />in proper condition for transport. The materials described on this manifest are not <br />subject to federal hazardous waste <br />regulations. <br />Date <br />Printed:Typed Name <br />Signature <br />'i "' '' <br />Month <br />Day <br />Year <br />T <br />17. Transporter 1 Acknowledgement c(Receipt of Materials <br />Data <br />R <br />A <br />Namo <br />Signafuie <br />s <br />Month <br />Day <br />Year <br />..PlintedtTyped <br />p18. <br />Transporter 2 Acknowledgement of Receipt of Materials <br />Dale <br />R <br />T <br />Pr':ntedtTyped Name <br />Signature <br />Month <br />Day <br />Year <br />E <br />R <br />19. Discrepancy Indication Space <br />A <br />C <br />20. Facility Ormer or Operator: Certification of receipt a( the wasta materials covered <br />by this manifest, except as noted in <br />item 19, <br />L <br />' <br />Date <br />T <br />PrintedrTyped Name 4Signature <br />Morrill <br />Day <br />Year <br />Y <br />621>5806 rm:r.iabulmasfor.com <br />wino mt <br />�� OViNK_ <br />Rev. 3rTJ5 <br />