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NON -HAZARDOUS WASTE MANIFEST <br />Please print or type (Form designs for use on elite (12 pkch) typewriter) <br />NON -HAZARDOUS 1. Generator's US EPA ID No. ManlIW <br />WASTE MANIFEST Doeum.!-,_ <br />3. Generator's Name and Mailing AddressC <br />4. Generator's Phone <br />5. Transporter 1 Company Name 6. US EPA ID Number <br />r�'r} _ AStt T <br />`�f fQ %DI'IJL Fp_. � <br />7. Transporter 2 Company Name <br />9. Designated Facility Name and Site Address <br />)t J5, C, AT /!-( <br />J)bs - C J,(rcrcr'r- RC) <br />g u CA, <br />11. WASTE DESCRIPTION <br />8. US EPA ID Number <br />10, US EPA ID Number <br />66ieCC 13T,� �� <br />. a e ransporters ID <br />B. Transporter 1 Phone <br />C. State Transporler's ID <br />D. Transporter 2 Phone <br />E. State Facility's ID <br />2. Page 1 <br />Of <br />F. Facility's Phone <br />707-57 <br />12. Containers 13, 14 <br />Total Unit <br />No. Type Quantity W1.Nol. <br />�•I a. <br />l ct i--( <br />G b. 1 <br />E <br />N <br />E <br />R c. <br />A <br />T <br />O <br />R d - <br />W �.. <br />N G. Additional Descriptions for Materials Listed Above H. Handling Codes for Wastes Listed Above <br />C �C M— BjL(�(JlU <br />MI rDS — ►IJ <br />N 15. Special Handling Instructions and Additional Information <br />r <br />Z <br />O <br />Z <br />16. GENERATOR'S CERTIFICATION: I hereby certify that the contents of this shipment are fully and accurately described and are in all respects <br />in proper condition for transport. The materials described on this manifest are not subject to federal hazardous waste regulations. <br />Pdnted/Typed Name <br />j <br />i <br />Signature <br />Month <br />Day <br />Year <br />T <br />17. Transporter 1 Acknowledgement of Receipt of Materials <br />R <br />Date <br />A <br />Printed/Typed Name <br />�v>` c 4, <br />Signature <br />P <br />r <br />U <br />J/ <br />p <br />R <br />18. Transporter 2 Acknowledgement of Receipt of Materials <br />Dale <br />T <br />E <br />Printed/Typed ed Name <br />YP <br />Signature <br />Month <br />Day <br />Year <br />R <br />19. Discrepancy Indication Space <br />F <br />A <br />20. Facility Owner or Operato(; Certification of receipt of the waste materials covered by this manifest, except as noted in item 19. <br />1 N� i21 �T 11J C <br />Date <br />T <br />Y <br />Printed/Typed Name ! / <br />/ �' i (� 11)�� t Lt 1" 11l �J <br />Signature <br />f� !� <br />Month <br />Day <br />Year <br />F-14 <br />©2002 LABELAASTER0 (800)621-5808 www.labelmesier.com <br />aeirumr <br />Rev. 3/95 <br />tNK - <br />