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WASTE MANN. T <br /> NO AZARDOUS • <br /> Please print or type {Form designed for use on elito 02 pitch)typewriter) Manifest 2'Page 1 <br /> NON-HAZARDOUS 1.Generators US EPA ID No. Document No. ;�yr#�—� of <br /> WASTE MANIFEST L.0 '412 501 151 <br /> 3.Generator's Name and Maiiing Address - <br /> tlifi. i .�•w• CI :1 ;racar3 — :���Z; ?3G .salfwrt'�t� <br /> 5.7;]'� .x'13,3jla Street. �a <br /> 4.Generators Phone( 32 3) <br /> ?54-5 111 - , <br /> 5.Transporter 1 Company Name - _ 6. tJSriEPA ID Number �rA - A.State Tansporferis SD <br /> . .CS1C• •^ 'a 9,1) 1� 7 B.YransPoRerl Phone : 3 "� •, 9 � ',� <br /> «, <br /> 7.Transporter 2 Company Name� - B.- US EPA 4D Number C.State Transporters ID <br /> . D.Transporter 2 Phone <br /> 9.Designated Facility Name and Site Address 10. US EPA ID Number E.State Facilitys ID <br /> Pavirxvae— ta <br /> .. 'r, F.Facility's Phone <br /> 3200 B. rroat•wr. tr 3t <br /> aa;teia C.3. 921305CXL 'rn,1) 21`0 519 <br /> I <br /> _ 12. Containers - 13. 14. <br /> 1 t.WASTE DESCRIPTION Total Unit 1 <br /> No. Type Quantity Wt.rVol- <br /> E <br /> N <br /> R I <br /> A <br /> LU <br /> ~ tl. , <br /> Additional Descriptions for Materials Listed Above H.Handling Codes for Wastes Listed Above <br /> 72 � I <br /> ca <br /> CI <br /> N 15,Special Handling lnstructionsand Additional information J14 Sin: -tac+ {tae: "Facility <br /> Z CLOVE 100=13LSS <br /> Z : . � -533-5577 <br /> 16,GENERATOR'S rconldon for transport.The materials described that on this macontents nifest are not subject subject[dent are llfede aand lhazard us wasteed and are regula[regulations. <br /> all-respects <br /> Date <br /> Printedrryped Name Signature Month Day Year <br /> f1�J/fir S� �:����. �•� <br /> T 17.Transporter 1 Acknowledgement of Receipt o1 MaterSals <br /> r Date <br /> R1. Month Day Yea <br /> A PrirteedPme - T <br /> alf2r , _ � <br /> S �� 2 .G .h <br /> � 18.Transporter 2 Acknowledgement of Receipt of Materials - Date <br /> R <br /> R PrintedfTyped Name Signature - Month Day Year <br /> - <br /> E <br /> R I <br /> 19,Discrepancy Indication Space <br /> F <br /> C <br /> 20.Facility Owner or Operator;Certification of receipt of the waste materials covered by this manifest,except as noted in item 19. - <br /> h' i Dale <br /> 4 T PrintediTyped Name Signature Month Day Year <br /> F-1482002. L.ABFJ.I"I/15TFJt®f800}fi21-5808 www.labelmaster.comSSI.�PRINTEDONRECYCLEDPAAER ^,„�.,a.�� _ Rev.31 <br />