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W <br />H <br />N <br />d <br />cn <br />rM. <br />O <br />in <br />cc <br />d <br />N <br />d <br />tI <br />Z <br />Z <br />NON -HAZARDOUS WASTE MANIFEST <br />Please print or type trorm designed for use on elite (12 pitcht Ivoewnter, <br />NON -HAZARDOUS <br />r-14®2002 i.ABEIi$ <br />1, Generator's US EPA ID No., <br />F <br />Manifest <br />Document ND. Fv�,A=%-r <br />4 ry 2. <br />Page 1 <br />r E <br />,? <br />f <br />WASTE MANIFEST�t <br />�r <br />3. Generators Name and Mailing Address <br />4. Ge6erat6es Phone <br />S. Transporter t Company Name 8. <br />US EPA ID Number <br />A. Slate Transporters ID <br />f �r <br />4..� <br />S. Transorter1Phone <br />P "( <br />1. Transporter 2 Company Name 8, <br />US EPA ID Number <br />C. State Transportees to <br />D. Transporter 2 Phone <br />9. Designated Facility Name and Site Address 10. <br />US EPA 10 Number <br />E. State Facility's ID <br />c <br />L �. yJ <br />F. Facility's Phone <br />�'.�jEs�.� 3 � .§'•A _. :� •�"" � <br />It <br />It <br />11. WASTE DESCRIPTION <br />12. Containers <br />Unit <br />T13, otal <br />No, Type <br />Quantity] <br />WtJVoI. <br />f.j=:(f't� - } <br />G <br />b• <br />E <br />N <br />E <br />R <br />g. <br />A <br />T <br />Q <br />R <br />d. <br />G. Additional Descriptions for Materials Listed Above <br />H. Handling Codes for Wastes Usted Above <br />15, Special Handling Instructions and Additional Information <br />18. GENERATOR'S CERTIFICATION: I heroby contly that the contents of this shipment ate full yy and accurately described and are In all respects <br />hazardous <br />In proper condition for transport. The materials described on this manifest ate not <br />subject to (ademi waste <br />regulations, <br />fl <br />Date <br />PrintedfTyped Name <br />Signature 'y f <br />l.•`S <br />i, ' . <br />dnth <br />ply tY r <br />jj(n� <br />..', A f ✓- Jt'ii it <br />IC 3 ...,�1 .^t <br />lY•r` i <br />r <br />F <br />TR <br />17, Transporter 1 Acknowledgement of Receipt of Materials <br />Date <br />A <br />PrintedfTyed.Name } <br />5g to <br />onth <br />pay Year <br />r <br />p18. <br />Transporter 2 Acknowledgement of Receipt of Maladais <br />Date <br />R <br />T <br />Pdntedtryped Name <br />Signature <br />Month <br />Day Year <br />E <br />R <br />19, Discrepancy Indication Space <br />F <br />A <br />C <br />20. Facility Owner or Operator; Codification of recelpt of the waste materials covered <br />by this manifest, except as noted in <br />item 19. <br />' <br />Data <br />T <br />Printed/Typed Name <br />Signature <br />Month <br />Day Year <br />Y <br />(ASTFA® (800)621.5808 wwvr.labeimaster.com <br />Rl�lktl MI <br />� YINK <br />Rev. 3/95 <br />