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NG,.�AZARD.O�US.INASTE .MANS , T <br /> Pleas€print <br /> .,,ye (Form designed fer'use on elite pitch)typewriter) - - - <br /> �! _ - Manifest 2.Page 1 x-- <br /> -NOWHAZARDOUS 1.Generator s US EPA ID No. Document No. <br /> WASTE=MANIFEST CV0 _ 112 513 25 -'a �f 1 <br /> S:Generators Name and Mailing Address_ - - - <br /> 52�J�1 -'i la Street, mal� .rte,� '�. �<.140 <br /> 4.Generators Phone{.-37—.3 254—:5200 - <br /> r 6,- US EPA ID Number '' A.State Transporters ID <br /> 5.Transporter 1 Company Name' <br /> -�_ Mah-' r` M 2,:'13 -: B.Transporter 1 Phone <br /> 7.Transporter.2 Company.Name B. US EPA ID Number, C.State Transporters 11) <br /> D.Transposter2 Phone <br /> 9.E)esignated Facility Name and Site Address 10.` - U5 EPA ID Number • E.Slate Facility's Ip <br /> Brx0a.:ie _ - F.Facility's Phone - <br /> �', finL:� C%. 333 ' 000 .1213 -3135�s -637-1352- <br /> 12. Containers- 13. - 14 <br /> 1 i. ASTE DESCRIPTION. .- - - - Total 'UnA <br /> No. J Type Quantity" W1Nol: <br /> 7 <br /> G b. <br /> E_ <br /> T <br /> 4 <br /> d. F l� <br /> +a 'G.Additional Descriptions for Mate rials Listed Above H.Handling Codes for Wastes Listed Above { <br /> CAI_ <br /> N' 15.Special Handling Instructions and Additional Infoail'lation. TaT t--n -s:C?C t ori �ftci_ l t y <br /> �����ry - tib• .�. -5 - <br /> _ t. 952 <br /> AWAW <br /> - - 16.GENERATOR'S CERTIFICATION:I hereby certify that the contents of this shipment are fullyyland accurately described and are in all respects <br /> in proper condition for transport.Tho materials described on this manifest are not Subject to to <br /> deral hazardous waste regulations. <br /> Date <br /> Printedi Typed Nam <br /> t - S€griature :y^ 14'1 - Months/ Day Year --,* -•�' <br /> Ki ' PC) moi..+' <br /> TT 17.Transportdr 1 Acknowledgement of Receipt of Materials7. - - Date ' - -'.- <br /> A PrIntedlTyped Name Signa_tine '_ 'Mont Day Year <br /> s 47 <br /> - p 18.Transporter 2 Acknowledgement of Receipt of Matedals - - - Date <br /> T' Month 'Day' Year <br /> Printed/Typed Name Signature , <br /> E a <br /> s Fi <br /> F 19.Discrepancy Indication Space - - •• -�i - _ } <br /> �'ir�j�' 1..5I vt- f v7. i <br /> - �S . d - i <br /> 20.Facility Owner or Operator.Certification of receipt of the waste materials covered by this manifest,except as noted in item 19. - - - - <br /> L Date i <br /> PrintedrTyped Name ,, Signature Moor "ay <br /> / Year <br /> e <br /> Rev-3195•� -' <br /> -F-1402002 I.ABElAItiSTFR O{800)(321-5808 wwW.labetmaster.corrt PRINTEDON RECYCLED PAPER eiwrto warn - - <br />