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NONHAZARDOUS WASTE MANIFEST <br />Please print or typo (Form dasignev for use on olifa:(t2 pitch) typawrltar} <br />GF14 02002 LABEL NiASTER ® (800) 621-580 <br />NONHAZARDOUS <br />1. Generator's US EPA ID No. <br />Manifest <br />2. <br />Page t <br />s <br />' �, <br />DocumantNo, <br />WASTE MANIFEST <br />iii 5?i> - <br />r <br />of <br />„ 3. Genaralor's tame and Mailing Address <br />_ <br />�-"'<t'� :`OM1_ �. �,.. r•--... <br />_ <br />4. Generators Phone <br />5. Transporter 1 Company iValna <br />US EPA ID. hjumber. <br />A State Transporter's 10 <br />_61 <br />iii , ...:. i. '• �... t-: :. -rF: ^ <:��:. :ib <br />in€ <br />1. <br />i.�. <br />- <br />..u<.__ ..._ <br />_ <br />_.. �, ,, .. as ._._.,". ,z� <br />B. Transporter 1 Phone <br />- <br />7. Transporter 2 Company Nama 0, <br />US EPA 10 Number <br />C. State Transporters ID <br />0- Transporter 2 Phone <br />9. Designated Facility Name and Site Address 10. <br />US EPA 10 Number <br />E. State Facility's ID <br />` <br />LS:.s€3 °''a'.1, <br />...i <br />Kul? <br />.`. ,. f', :w <br />F. Facility's Phone <br />I I WASTE DESCRIPTION <br />Containers <br />1.3. <br />14. <br />Total <br />Unit <br />No. <br />Type <br />Ouantity <br />VJLNoL <br />11 F <br />G <br />b. <br />E <br />N <br />E <br />R <br />° <br />A <br />T <br />O <br />R <br />d- <br />0, Additional Descriptions for Malefials Listed Above <br />H. Handling Codes for Wastes Usled <br />Above <br />g <br />15. Special Handling Instructions and Additional Intormatien <br />16. GENERATOR'S CERTIFICATION: I hereby certify that the contents of this shipment <br />are full yy and accurately described and are <br />In all respects <br />in proper condition for transport. The materials described on this manifest are not subject <br />to redeml hazarxdous waste regulations. <br />Date <br />Nama s._ <br />Signature g <br />fir ri 4 <br />Month <br />Day <br />Year <br />UPon�leclffpedy��- <br />6tr00 <br />T <br />17. Transposer t Acknowledgement of Receipt of Materials. <br />Date <br />A <br />Printed/Typed Name 's <br />Signaldra r '4 <br />Month <br />Day <br />Year <br />S <br />lo <br />O <br />1➢. Transporter 2 Acknowledgement of Receipt of Materials <br />Date <br />R <br />T <br />PrintedtTyped Namo <br />Signature s <br />Montt) <br />Day <br />Year <br />E <br />°. <br />R <br />19. Discrepancy Indication Space <br />F <br />A <br />G <br />L20. <br />Facility Ovater or Operator: Certification of receipt of the waste materials covered by <br />this manifest, except as noted in item 19. <br />' <br />Date <br />T <br />Printedrryped Name <br />Signature <br />Month <br />Day <br />Year <br />Y <br />8 www.lIIboimasler.com <br />F'Mtttcv A'hCFDnKR � <br />-:SOYINK <br />