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FR*#### ### # # OCC 0000000 P. 4 <br /> NON-HAZARDOUS 1. Generator's U$EPA ID No. Manifest 2. Pape 1 <br /> WASTE-LAANIFEST ', <br /> 3, ener sN mond.Mailing Address <br /> 4. enoratnr Flion( -ter (� ) <br /> 3. .7ra s r►erGom,panlr Nama iS, US EPA ID Number .,._., A. Transporter's Pbane. <br /> 41, <br /> , Transporter 2 Company Namo wv & US EPA ID Number B. Transporter's Phone <br /> i 9. DesApoted Facility Name and Site Addre.s� 10, US EPA ID Number C, Facdity'S.Phono <br /> 5 <br /> �..., <br /> 1 I. Woste Shipping Name and Description~ 12. Containers 13. .� 14. <br /> Total Unit <br /> Nv, I Type Quantity Wt Val <br /> N <br /> E <br /> R <br /> A e. <br /> 7i <br /> d. <br /> O <br /> D.. Additional Qcscriptions for Materials listed Above E_ Handling Codes far Wnxtas Lixted Above <br /> 1 <br /> 15,14paciai handling Inerudions and Addifienal Information <br /> -a-' <br /> IS.GENERATOR'S CERTIFICATION: I certify th®materials described above gn this manifest aro not subject to feclwol regulations for reporting prepot t%4®sol ofyhazwdovs Wv5N. <br /> Printed/Typed Name V .,� Signature Month Day Year <br /> T 17,Transporter 1 Acknowledgement of Roceipt of Materials <br /> R Si nature + Month Day Year <br /> A Pri ted/TypediName 0 Via r/ -^" <br /> N <br /> S f ' J .L � <br /> - <br /> p18,Tronsporter 2 Acknowledgement of Receipt of Materials <br /> TPrintad/Typed Name Signature Month Day Year <br /> E <br /> R <br /> 19.Discrepancy Inckotion Space <br /> F <br /> A <br /> C <br /> L 20,Facility Owner or Operator Certif1coti6n of receipt of wosto materials covered by thl}manifest except as noted in Item 19. <br /> 1 <br /> T <br /> Y - <br /> Printed/Typed Nome Signature Month Day Year <br /> GENERA. OR•S GORY <br />