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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) <br /> I.Generator ID Number 2.Pag 1 of 31 erga)cy egponse Phone 4.Waste�a%l0q trJpmber <br /> NONHAZARDOUS pvA <br /> WASTE MANIFEST <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> thwyev�:+2rPcwafk»r AM: <br /> 819 N Rol S1r?at <br /> %relder►,c;A,35202 <br /> Generator's Phone: 'NTT'44 It-H184 <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> NIRC 6wl oMMIrtal 50(wea IW- A kp00i'l30114 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Addressuri U.S.EPA ID Number <br /> Y Gc�%y Cev+trel I.arrrJl+N <br /> 44ON Couay Road 2W I <br /> Wo�t#artA,C4 �5T d11 <br /> Facility's Phone: 53(!-fst19-A775 <br /> ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Packing Group(if any)) No. Type Quantity Wl.Nol. <br /> 1. <br /> d' <br /> aWin H&MCIMS VYrtste,SOW.0S1trdJIt V41'11v i, .� Y <br /> z 2. <br /> w <br /> ca <br /> 3. <br /> 4. <br /> 13.Special Handling Instructions and Additional Information <br /> POW 044-F41 Nttje�st ldlxriil 112ia-0 8'2 <br /> .................. <br /> €A tc Y 1)Y. Fr.WrMgrft <br /> 14. GENERATOR'S CERTIFICATION: I certify the materials described above on this manifest are not subject to federal regulations for reporting proper disposal of Hazardous Waste. <br /> Generatoes/Offeror's-Printed/Typed Name Signature Month Day Year <br /> 15,International Shipments <br /> ❑Import to U.S, Export from U.S. Port of entrylexit: <br /> Z Transporter signature(for exports only): Date leaving U.S.: <br /> W16.Transporter Acknowledgment of Receipt of Materials <br /> ,, Transporter 1 PrintedlTyped Name Signature Month Day Year <br /> 101- <br /> z Transporter 2Pn6ted/TypedName Signature C� Month Day Year <br /> Q <br /> F- <br /> t- <br /> 17.Discrepancy <br /> 17a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection Full Rejection <br /> Manifest Reference Number: <br /> 17b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J_ <br /> V <br /> LL Facility's Phone: <br /> 'LOU 17c.Signature ofAlternate Facility(or Generator) Month Day Year <br /> Q <br /> Z <br /> iDesignated Facility Owner or Operator:Certification of receipt of materials covered by the manifest except as noted in Item 17a <br /> ed/T ed Name Month Day Year <br /> yp Signature-C-11 6-GENERATOR'S INITIAL COPY <br />