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Lj <br /> �NOZ <br /> ARDOUS WASTE VANI <br /> " !ease Print or (Form designed for use on a;ite(12 pitch)rypewr4tar) - a 2.Page 1 <br /> Manifest' <br /> 1:Generator'S'US EPA ID No:.- Document No., of " <br /> ":NON-HAZARDOUS': , % ra7 <br /> WASTE-MANIFEST' ^_T 13�.. n ' <br /> I Generatofs Name and Mailing-Address' - - - <br /> J�ifii. ec3t�rn Attiz.: ?at ,sfi11r3iL, : . . .. <br /> �?�!3 S i i3�3';Strazt,, ��,nmerce; r�. �?�`►�. . <br /> 4.GeneratorsPhone( -323"7�j�4-1��}�. - . <br /> 5.Transporter 1 Company Name,- - - .6,' US EPA'ID Number -A:State Transporters lD - <br /> 7 <br /> a.Transporter l'Phone, -�I')( �t , - <br /> ' a "it3t 'gra �s'.:_.Inc.' tial. <br /> ' - 8. -, US EPA ID Number- _ C.Stata'Transporters ID <br /> 7.Ttansporter 2.Company Name . <br /> " - - o,Transporter 2 Pfione <br /> 9 Designated Facility Name and Site'Address,:- - - ...10. .US EPA 11)Number E.Stale Facility's ID' <br /> F.-Facility s,Phone.. <br /> IA 12 Containers i3. 14 <br /> Total <br /> ' . Unit <br /> TIDt+f .. .. . <br /> - 31.WASTE DESCRIP - " ' .' <br /> . .' Type _Quantity ,. WiNol. <br /> b. <br /> R � ... <br /> d. <br /> ,. <br /> s Listed Above <br /> - G.Additional Descdptwns.for Materials Usted Above`-`: _• - .- <br /> H..Hantlimg Codes for Wasta <br /> 4. <br /> t �.. <br /> 4 1, F. a. <br /> 17 <br /> 15 Special Handling.lastructiens and AddiGcnai Information t - - <br /> :Sits:: toc�c� ,::Fact ity° <br /> 990. Picca.1i'2'. <br /> !°9; 95215 <br /> f <br /> i6,GENERATOR'S CERTIFICATION:.thereby certify that the,contents of this'shipment are fullyy and accurately described and are in all respects <br /> *irnprope[.Cpndi(igntot transport.'The materials described do this manilest'ate norsabJect to fetleraS fiazasdous waste regulations <br /> ,. <br /> - <br /> Date -' <br /> Signator r Month Day Year <br />{ PrintedITyped Name. <br /> 17 Tran porter,l AdrnoyAedlwroent of Receipt of Materials.'. <br /> •�' <br /> Month;' Day. Year <br /> A' Printedliyped Name Signa_ _ ": <br /> R 1 B_Transporteo2 Acknowledgerisenl of Rodeipt of Materials Data - - <br /> �'. <br /> Printedll yped NaTlie Signature Month - Year <br /> E <br /> R <br /> -'19"Disc[epandi_IndicationSDace- - <br /> - ' <br /> ._20.Facility Owner or Operato'r,-Certification of recelOf of the waste materials ibvered by INS manifest,except as noted in item 19 - <br /> :::. .. <br /> :Date <br /> PnntedRypedName .Signature MonNi Day -Y6ar <br /> F-1402D02 :-UDE1��ASfER�I@i001621 .=wwrrlebelrna3t9r44oM piwrE.n ON tkcralDkkR' n»,r».n, ReJ-91 g5 <br />