Laserfiche WebLink
NO!_ ApdARDOUS WASTE MANR _S� <br /> Please pant or type (Form designed for use on elite(12 pitch)typewriter) <br /> 1.Generators US EPA ID No. Manifests '.`�?� 2.Page 1 <br /> NON-HAZARDOUS Document No. <br /> WASTE MANIFEST ' of t <br /> 3.Generator's Name and Mailing Address <br /> 'k;iia y 4- �.y,7wµ <br /> ,2'1, 1� Y�=.k r .Yr.w� �.�[�I TT f. <br /> _ I <br /> 4.Generators Phone( �� ?-), .-�1 'k'•' <br /> 5.Transporter 1 Company Name 6, US EPA 0 Number A.State Transporters ID <br /> -34rz Alai =i: T;:^. t(,s:7 ,i? ?1� �''? TY) <br /> B.Transporter)phone <br /> 7.Transporter 2 Company.Name - 8. US EPA Ip Number C.State Transporters ID <br /> A.Transporter 2 Phone <br /> 9.Designated Facility.Name and Site Address 10. US EPA ID Number E.Stata Facility's ID <br /> Ij <br /> r;,,:zr :x 3; ^;; y t r� F.Facility's Phone _ I <br /> 11.WASTE DESCRIPTION 12. Containers 13. - 14. <br /> Total Unit <br /> No. Type Quantity - r:'-. Wt.Nol. <br /> a. LL r <br /> G b. <br /> E <br /> N <br /> E- <br /> R c. <br /> A f <br /> T <br /> A <br /> R a. - <br /> _ G.Additional Descriptions for Materials Listed Abcve- - - H.Handling Codes for Wastes Listed Above <br /> 15.Special Handling Instructions and Additional Information J101-3 9i -..c3: ;01:-:_::Oz <br /> V7 r)F:.'r..i 1.3-')'l 5 <br /> ;IIIIII <br /> 16.GENERATOR'S CERTIFICATION:I hereby certily that the contents of this shipment are futly and accurately described and are in all respects <br /> in proper condition Ior transport.The materials described on this manifest are not subject to federal hazardous waste regulations. - - <br /> Date <br /> Printecirryped Name Signature Month Day Year <br /> T 17.Transporter-1 Acknowledgement of Receipt of Materials - Date <br /> R <br /> A PrintediTyped Name Signature ;. Month Day Year <br /> s A <br /> p 16.Transporter 2 Acknowledgement of Receipt of Materials <br /> Date <br /> TPrintecirryped Name Signature Month Day Year <br /> R 19.Discrepancy Indication Space <br /> F <br /> C ; <br /> 20.Facility Owner or Operator,Celt fication of receipt of the waste maWrral3 crovered by this manifest,except as noted in item 19. - <br /> Date <br /> T Printedrryped Name ° Signature ' Month Day Year <br /> Y w <br /> F-1402002 LAKLAASTOtO000)Q13608 V-W-labelmaster.com PAWMDONRECYCLED PAPER <br /> � Rev.3195 <br /> a4rr7r55fi1 cwr:cnvuwur. II rCJJ! ruv <br />