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NON-HAZARDOUS WASTE MANFEST <br />mease prim or ypig <br />' I NON-HAZARDOUS <br />WASTE MANIFEST <br />1. Generator's US EPA ID No. Manifest <br />Document No. <br />2 Page I <br />of <br />I I 3. Generators Name and Mailing Address <br />Generators Phone <br />Transporter 1 Company Name 6. US EPA ID Number A. State Transporters ID <br />I B. Transporter 1 Phone <br />7. Transporter 2 Company Name a. US EPA ID Number C. State Transporters ID <br />I D. Transporter 2 Phone <br />9. Designated Facility Name and Site Address 10. US EPA ID Number E. State Facility's ID <br />I <br />F. Facility's Phone <br />I 1 11. WASTE DESCRIPTION 12. Containers <br />No. Type <br />13. <br />Total <br />Quantity <br />14. <br />Unit <br />WtJVol. <br />a. <br />li <br />G <br />E <br />N <br />E <br />R <br />A <br />T <br />0 <br />R d. <br />G. Additional Descriptionator Materials Listed Above H Handling Codes for Wastes Listed Above <br />15. Special Handling Instructions and Additional Information <br />.., • . ...... , <br />ar• ASsarajNi. al 41111111IIIMMIWINIMI <br />16. GENERATOR'S CERTIFICATION: I hereby certify that the contents of this shipment are fully and accanudrastteldheazscanr'dbeodusawnda:treeriengaulllartmects <br />In proper condition for transport. The matenals described on this manifest are not subject to federal <br />I 1 Date <br />Printed/Typed Name 1 Signature Month Day Year <br />I I <br />T 17. Transporter 1 Acknowledgement of Receipt of Materials Date <br />R <br />A <br />N <br />S <br />Printed/Typed Name <br />.._ <br />1 Signature Month Day Year <br />I I <br />P 0 18. Transporter 2 Acknowledgement of Receipt of Materials Date <br />R T <br />E <br />R <br />Printed/Typed Name I Signature Month Day Year <br />I I <br />F <br />A <br />C <br />19. Discrepancy Indication Space <br />I 20. Facility Owner or Operator, Certification of receipt of the waste materials covered by this manifest, except as noted in item 19. <br />L <br />I Date <br />I <br />Y <br />Printed/Typed Name Signature Month Day <br />I <br />Ye2r