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NONHAZARDOUS WASTE MANIFEST <br />Pioaso <br />IF <br />F4402002 I.AOEI.MASTER® (800) <br />print or typo <br />{c=orm aestgned roc use on cote {Tz <br />pncnl rypowmeq <br />ad <br />NONHAZARDOUS <br />1. Generator's US EPA <br />Ib No. <br />Manifest2. <br />r, <br />Page i <br />Document No. i ' ''' <br />a <br />WASTE MANIFEST <br />1 <br />of <br />3. Generator's Name and Mailing Address _ : el. <br />_ <br />IFFFF <br />x <br />J. Generator's Phone( ]' -IF1 r --, t <br />.:. r ..FIF.: <br />Be Transporter 1 Company Name <br />G, <br />US EPA Ib Number <br />A. State Transporter's ID a ':�::r ` <br />"FF n <br />f �.. <br />;:; <br />` t` - -� - <br />Be Transporter 1 Phone <br />;,.. 1 <br />_ew <br />7. Transporter 2 Company Name <br />8, <br />US EPA ID Number <br />C. State Transportoes Ib <br />Q.Transporter 2 Phone <br />9. Designated Facility Name and Site Address <br />10, <br />US EPA 10 Number <br />E, State Facility's 10 <br />r C <br />FI Z IF <br />IF IF <br />E <br />F. Facility's Phone <br />. _ - -F <br />..+ _ee. <br />_ <br />FW <br />_IF <br />IF <br />IF}IF <br />- :. ::.FeFFF: <br />Ir IF <br />Fe' <br />_ .,..04 <br />III. <br />IF <br />W <br />Fee <br />11. WASTE DESCRIPTION FF <br />12. Containers <br />13, <br />14, <br />TotalUnit <br />No, <br />Typo <br />Quantity <br />WIeNol- <br />a. <br />:`Fig <br />IF <br />FYI IF <br />G <br />b. <br />E <br />N <br />E <br />R <br />r:. <br />A <br />T <br />Q <br />R <br />d. <br />Me <br />G. Additional Descriptions for Materials Listed Above <br />H. Handling Codes for Wastes Listed Above <br />15, Spacial Handling Instructions and Additional Information <br />r. n <br />IF ti <br />4 ' <br />. _ <br />16. GENERATOR'S CERTIFICATION: t herebyy certify that the contents of this shipment are fully and accurately described and are in <br />all respects <br />in proper condition for transport. The matorfais described on this manifest <br />are not subject <br />to federal hazardous waste regulations. <br />Data <br />PrintedlTypedNamo W --• <br />SignatureFee <br />PI <br />Month <br />,Yar <br />DayFIF <br />.,IF <br />We It <br />.4 <br />FIFY <br />T <br />17, Transporter 1 Acknowledgement of Receipt of Materials. <br />` <br />Dale <br />R <br />A <br />Prinled/Typed Name ;l <br />Signature <br />Month <br />Day Year <br />N <br />S <br />P <br />IF <br />18. Transporter 2 Acknowledgement of Receipt of Materials <br />Date <br />R <br />T <br />Printed/TypedName <br />Signature <br />Month <br />Day Year <br />E <br />R <br />19, Discrepancy Indication Space <br />F <br />A <br />C <br />1 <br />20, Facility Owner or Operator; Certification of receipt of the waste materials <br />covered by this manifest, except as noted in item 19. <br />L <br />' <br />Date <br />j <br />Printed/Typed Name <br />Signature <br />Month <br />Day Year <br />Y <br />621.5608 wvnv,inbetmaster.com <br />caro xrt <br />INK <br />Rev, 3195 <br />