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-��iJrigH � •f �s� <br />71- <br />Please print or type. (Form designed for use a; of -itch) typewriter.) Form Approved. OMB No 2 0 -Dass. a ' <br />Style CF18 LAKLIRASMO(soo)ez13 v. w.'.mewnaur.cem <br />® nwrrEcatovu <br />urweouw .N <br />EPA Form 870042A (Rev 9-88) rrevious emuons are oasoiere. <br />GENERATOR COPY <br />UNIFORM HAZARDOUS <br />121. G tors US EPA ID No. Manifest Document'.1111 <br />F22. Page <br />Information in the shaded <br />WASTE MANIFEST <br />I <br />areas is not required by Federal <br />(Continuation Sheet) <br />c _ r:, .+ a u <br />of <br />law. <br />23. Generator's Name <br />L. State Manifest Document Number <br />Df L i»k.CO vINE'::.• t,s <br />3F20411 r: -t,. <br />I:'t1U1 s iiwY y,, <br />w <br />$tateceheratoeslD <br />-, <br />24. Transporter Company Name 25. US EPA ID Number <br />N: State'Transporter's ID ',^I <br />9, Transporters Phone. <br />26. Transporter Company Name 27, US EPA ID Number <br />P. State Transporter's ID <br />0:Transporter'sPhone <br />29. Containers <br />30. <br />31. <br />R. - <br />28. US DOT Description (Including Proper Shipping Name, Hazard Cless, and ID Number) <br />Total <br />Unit <br />..Wast No. <br />r—H—M1 <br />No. <br />Type <br />Quantity <br />WWol <br />a. <br />NO'!h. LI4•I1ID ((.IT,, DIRT) <br />jj �y�p� <br />952` <br />b. <br />C. <br />Groy` <br />d <br />N <br />E <br />R <br />T <br />f. <br />r <br />9 <br />h. <br />i. <br />S. Additional Descriptions for Materials Listed Above <br />T. Handling Codes for Wastes Listed Above <br />28a. f}3ub.i4tioLs i..�, ,., - :;.- r.n;,�•F'ft'1+^. <br />32. Special Handling Instructions and Additional Information y:ET+i, APER. >&RIATE rhOTECTIVE GEAR WJJEH NAEDLI NG. <br />EhtFFUG�PIC C• T+'!1 is .: t = a n_ r:l. CALLEY, MUST IDEMrY MVAR USA AS <br />3141PPFif . <br />FLRCA:L� 2 .,-, 1Fr, YT" ::;NO DRIVER 5Ii9HATURE . <br />T <br />33. Transporter _ Acknowledgement of Receipt of Materials <br />Date <br />R <br />Primed/Typed Name <br />Signature <br />Month Day Year <br />NS <br />P <br />34. Transporter _ Acknowledgement of Receipt of Materials <br />Date <br />T <br />Printed/Typed Name <br />Signature <br />Month Day Year <br />E <br />R <br />35. Discrepancy Indication Space <br />A <br />c <br />I <br />L <br />1 <br />T <br />Y <br />Style CF18 LAKLIRASMO(soo)ez13 v. w.'.mewnaur.cem <br />® nwrrEcatovu <br />urweouw .N <br />EPA Form 870042A (Rev 9-88) rrevious emuons are oasoiere. <br />GENERATOR COPY <br />