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i <br /> NG_ IAZARDOUS_WASTE MAI,7-ST <br /> Please print or type (Form designed for use on elite(12 pitch)typewriter) 2..Page,1Manifest <br /> ' <br /> NON-HAZARDOUS 1•Geneiators uS EPR 0No Document No. <br /> WASTE MANIFEST <br /> 3.Generators Narrie and Mailing Address- <br /> 4.Generatars.Phone( _7 3) 21- <br /> 5.Transporter 1 Company Name 8 US EPA ID Number:-:,, A State Transportars!D " 1 <br /> n <br /> n <br /> • B:Tranapoiter i Phone� .1r�1 s ste <br /> - <br /> - <br /> 7.Transporter 2 Company Name' - - 8 US EPA Ip Number '. -C.State Transporters ID 7 <br /> D.Transporter 2 Phone <br /> 9.Designated Facility Name and Site Address 10. US EPA iD Number E State Fao llty's ID i <br /> 1 7 F.Facility's Phone - <br /> 1: ell. „•1 : )j._l.. _.,Jo �-)tj 7i yew <br /> x , <br /> _ - - :12: Cohtafners 13: - 14.- <br /> tt.WASTE DESCRIPTION Total Unit <br /> No. Quantity-Type'- <br /> . .” Yp <br /> a. <br /> ��? ' 11?i:' X7.1 y '.k" " <br /> .. Y <br /> n <br /> g e I <br /> N <br /> A <br /> T ; <br /> UJI <br /> f T = H.Handling Codes for Wastes Listed Above <br /> G.Additional Descriptions for Materials Listed Above <br /> i <br /> - 3. €1;7;`L—:•L3:'..iiT': :7`,23 »if. 3.T' <br /> Q15,Special Handling Instructions and Additional Informtlon <br /> CU�'i <br /> 40 <br /> I$.GENERATOR'S CERTIFICATION 1 horeby certify that the contents of this shipment are fully and accurately described and are'In.alI respects <br /> .In proper condition for trans on.The_materials described on this manifest are not subject to federal hazardous waste regulations. ; <br /> .: r" <br /> i Data <br /> Month r'Da Year <br /> PnntedlTypedName Signature Y <br /> r1 L31 <br /> T 17.Transporter f Acknowledgement of Receipt of Materials J Date <br /> I q Prin edrr d Name Signature/�! l' J' Van Day': Year <br /> bZ1 <br /> P <br /> .18.Transporter 2 Acknowl gement cf Receipt of Materials j <br /> Date <br /> * PrinledlTyped Name. - Signature.:.. Month Day Year j <br /> 19.Discrepancy Indication Space, : <br /> 20.Facitity Owner or Operator;Certification of receipt of the waste materials covered by this manifest,except as noted in Item 19., - <br /> c <br /> Date. <br /> T Printedlfyped Name Signature Month Day f Year <br /> Y. I <br /> 1i �Fi t LAVE III, B214M.w"IahBlma3tBYA0A1 i• PANTED ON RECYCJ ED PM_HI��}�j r.�uno w�ir� Rev:•3195 w, I <br /> - .. .. - ® USING SOYBEAN INK It�ISMINK <br />