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N0h AZARDO.US WASTE <br /> MANW <br /> Please print of type (Form destgned for use on elite(12 pitch)typewriter) Manifest 2,Rage 1 <br /> ' <br /> NONHAZARDOUS 1:Generators US EPA iD No..:' Document No. . j�j'}) of <br /> WASTE MANIFEST ' ` <br /> 3.Generators Name and Mailing Address <br /> i tlrf i 1 1 C:?r z �rflcerj --Atter: ?-It <br /> 4.Generators Phone( 32j3 284-32-al - <br /> - 1 B. US EPA ID Numher � A.State Transporters ID, _ <br /> 5.Transporter 1 Company Name - y�s `3 <br /> _ F INT 030',0 C '11 - B.Transporter t Phone <br /> C.Slate Transporters ID <br /> 7.Transporter 2 Company Name - B. US EPA ID Number - - <br /> D.Transporter 2 Phone <br /> g,Designated Facility Name and Site Address 10. U5•EPA 1D Number E.State Facility's ID - <br /> ra <br /> .� F.Facility's Phone <br /> 3200 .Z. Frx%teri Strtat �\ s 714-53-1-13137 <br /> � ia'ALUL4 {; • 9233-) � t�;? r3 � 13. - <br /> 12 Containers 14. <br /> 11.WASTE DESCRIPTION Total Unit <br /> t <br /> No. Type Quantity W1.Nol. <br /> a. <br /> G b. <br /> Q - - H.Handling Codes for Wastes Listed Above <br /> G.-Additional Descriptions for Materials Listed Above - <br /> axv-hazantxja -,4a It ir <br /> N 15.SpecialHandling Instructions and Addmonalflnformaiion j01-b rSj.fa:? stackta-,i F'3C���r� ' <br /> nceali 'RI. <br /> _ fiat:Jffill.77 S> ;A 10�'GLZS <br /> 952I 5 <br /> 07 i3 <br /> if 16.GENERATOR'S CERTIFICATION:I hereby certify that the contents of this shipment are fully and accurately described and are in all respects - <br /> in_ proper condition for trarisport.The materials described on this manifest are not subject to federal hazardous waste regulations. <br /> Date <br /> Signature v. Month Day Year <br /> Printe Yped Name, �'` <br /> �, Date 1 1161"6) <br /> T 17.Transporter 1 Acknowledgement o1 Receipt of Materials <br /> - <br /> R SignatureMonth Day Year <br /> i ; :`. '', _ <br /> A PrintedlTyped Name t1 <br /> '-' [ ✓ <br /> o 4-40 <br /> � ." Dale <br /> 18.Transporter 2 Acknowledgerrient of Receipt of Materials <br /> 0Signature Month Day Year <br /> T. <br /> Printedrryped Name <br /> E <br /> _ R <br /> 19.Discrepancy Indication Space_ - <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 <br /> 7 - ,. - _ -Signature - - Month Day Year - - - <br /> PdntedlTyped Nama <br /> Y , <br />! - - >- -AS Rev. <br /> ' F-1402002 L/1aE11"j0(S00)621SWS WWW.t"ma$ter.COM �pgn7TE[}OH RECYCLED9IPEFteu,Euwn ' <br /> -,W,mvgcw ttNE J Sl1V i1�YK <br />