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NONHAZARDOUS WASTE MANIFEST <br />Please print or type (Form designed for use on elite (t2 pitchy typewriter, <br />CF14 02002 I.ABELMASTER® (800) <br />NON -HAZARDOUS <br />1. Generator's US EPA ID No. <br />Manifest <br />2. <br />Page 1 <br />WASTE MANIFEST <br />r�:.`;f.{i'f,NfPftS <br />Document No. �<���� =� <br />ar <br />t <br />30piftes_Name and Mailing Address <br />-94F` APb X <br />4. Generators Phone ( .uL s <br />6. Transporter 1 Company }Varllo 6. <br />US EPA IID �1 Oar, �[ <br />aiRn <br />A. Slate Transporter's ID <br />F3`ti�'5$3i.-i zHi=n€`i. ;xa-2'.3E <br />y.,t;"SF f �F„k,p <br />4 <br />1 Phone 400- <br />t•ti: <br />,51 b...:3 F°� <br />83 Transporter <br />-0 <br />7. Transporter 2 Company Name 8, <br />US EPA tO Number <br />C. State Tianspodees ID <br />D. Transporter 2 Phone <br />9, Designated Facility Name and Site Address 10, <br />US EPA ID Number <br />E. State Facility's ID <br />ma�yy0 <br />}}_ <br />Liam; 2L Aa5Z.%4'3 Rare <br />F. Facility's Phone <br />11. WASTE DESCRIPTION <br />Containers <br />130 <br />14, <br />Total <br />Unit <br />No. <br />Type <br />Quantity <br />Wt..Nol, <br />SUB <br />t <br />G <br />b <br />E <br />E <br />R <br />C. <br />A <br />T <br />O <br />R <br />d. <br />G. Additional Descriptions for Materials Usted Above <br />H. Handling Codes for Wastes Listed Above <br />3 kis1{�'i€ int S 27: Mp <br />15, Special Handling Instructions and Additional Information <br />16. GENERATOR'S CERTIFICATION: I hereby certify that the contents of this shipment are full and accurately described and are in all respects <br />Yaderal <br />In proper condition for transport. The materials described on [Ills manifest are not subject to hazardous waste regulations. <br />P ti <br />t <br />Date <br />P'rintedtTyped Name <br />Signaturdt j i <br />Montttr <br />Day <br />Year <br />•fig <br />i�J/4€ �,.+(� t <br />�' f <br />'`7 <br />r <br />r t i <br />T <br />17. Transporter 1 Acknowledgement of Receipt of Materials <br />' 1 V <br />f <br />Date <br />R <br />Name <br />r <br />Signature ' ���, <br />Monttr <br />Day <br />Year <br />NpdntedlTyped <br />�/ <br />u <br />O <br />18, Transporter 2 Acknowledgement cf Receipt of Materials <br />j €� <br />Onto <br />R <br />T <br />PrintedrTyped 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 />20. Facility Owner or operator Certification of receipt of the waste materials covered by this manliest, except as noted In Item 19. <br />I <br />Date <br />T <br />Printed+Typed Name <br />Signature <br />Month <br />Day <br />Year <br />Y <br />821-5808 www.labolmastor,com <br />�rorr,rtc,caranuca f <br />cs°c sv�u.ex r �sOVINJ <br />