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rldNAZARDOUS'WASTE MAN"T, <br /> Please print or type (Farm designed for use on elite(12 pitch)typewriter) <br /> s 1 Generato7s US:EPA <br /> AID No ` ' Manifest /' 2 e.t <br /> NON-RAZARDOUS Document No. o <br /> `WASTE MANIFEST °f <br /> 3.Gener'ator's Nams.and MaHijlg?Idtlress <br /> 4.Generators Phone - <br /> '5.-Tra sporter_I Company ame _ , - - 6 - US EPA ii)Number �� .�-'A.State Traruportaer ID - <br /> - B.Transporter t Phone <br /> ._-7.Transporter 2 Company.Name•,s, _ - - B.: US EPA-ID Number .- - ,C.State Transporter's ID <br /> x D.Transporter 2 Phone <br /> 9�esignated Facility Name and Site Address , '/ - 10 US EPA Ib Numher E State Facility's ID - - <br /> /A > + - F.Facilitys Phone <br /> wt <br /> -11.WA T DESCRIPTION - - '` - - X12..Containers - 13.' "14, - <br /> W48TE <br /> i - Total..- Unit <br /> No Type Quantity wt.Nol. I <br /> R :G <br /> O.. P <br /> W' a - <br /> yQy <br /> :G.Additional Descriptions for tenala Elated Above H.H�elol_l_14v <br /> andling Codes for Wastes Listed Above <br /> y <br /> V 15.S ial ndling Instructions a ddq'o al I onn <br /> -AV iff WAV <br /> 16.GENERATOR'S CERTIFICATION'.hereby"certify that:the conter4s of this shipment are,fully and,accurately described and are in all respects >.. e <br /> ;in proper condition for transport.The matenais described on this manifest are not subject federal,hazardous,waste regulations. <br /> r! <br /> Data <br /> PrintedlFyped Name Bignatuie --� i D Yea <br /> f. UAI <br /> b" J' <br /> ansporter l Acknowledgement of Receipt,ot Materials-1 ;Data <br /> ' q- <br /> MWedame - - Signature fh y <br /> IN <br /> '1 Trams iter 2 Acknowled ement a!Recei t'ot Materials - r <br /> t d' i PQ� 9 p Date <br /> 7"`ltntedlT" ]lame Signatyra Month: Day Ya Year. <br /> R ✓ r.:x' <br /> .19.Discrepancy Indicauori Space., <br /> C <br /> f -20 Facility Owner or Operator Certification of receipt of the wa`sfe materials covered,by this manifest except as noted in iters 19.'.•-<- - - _ <br /> T Printed/F Noma �{} Sign ure Month Day Year <br /> 5 <br /> F-1402002 1 11STER�(860)621�BU8 www.labelmaeter.ean - //'��� I <br /> .. - - .-, - - - - :.!i#PIYHIEU Ori RECYCLED PAVER r�. , ova w r - 's' ' Rev 3195. <br /> V'�i i1YTT'�if ��c�rsm�cl4 euK- IY.... �v�.�av - •+ <br />