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NON -HAZARDOUS WASTE MANIFEST <br />Please print or type (Form desirned for use on elite (12 ager) Wpeante) <br />CF14 02002 LASELAASTFA® gap) x213008 wwx.ldbelmaslaraem ..1� <br />�wmmp'Ni�Q[Dl�ka._ <br />VNNSOR.MM INK <br />LSI <br />NON -HAZARDOUS <br />1. Generators US EPA ID No. <br />Manifest �^ <br />Document No.n / 7J -i{ <br />2- Page 1 <br />WASTE MANIFEST <br />(� (/ ICI /sJ <br />L <br />of 1 <br />3. Genemror's Name d Mailing Address ✓417( <br />zi5 <br />Si�c�av� c� <br />4. Generator's Phone (M ) <br />S T der 1 Comp y Nam .r. e. <br />US EPA ID Number <br />A. Stale Transporter'. ID <br />B. Transporter 1 Phone <br />(% <br />7. Transporter 2 Company Name 8. <br />US EPA ID Number <br />C. State Transporters ID <br />D. Transponder 2 Phone <br />9. Designated Fadll Name and Site ss 10. <br />�ot�aril <br />US EPA ID Number <br />E. State Facility's ID - <br />> <br />Tl) E? I <br />F. Fadliry's Phone <br />11. WASTE DESCRIPTION <br />12. ttmers <br />13. <br />Total <br />14. " <br />Ung <br />No. <br />Type <br />Quantity <br />WINoI. <br />,/�,� ,/� <br />a. D� LIZQY' .!J S r i 1 `��3 GZ i ` <br />��.� �',.� <br />/p <br />e Yv <br />G <br />c <br />E <br />N <br />E <br />R <br />A <br />T <br />0 <br />R <br />d. <br />G. Addifknai Oes�cdptio for Materials Listed Above <br />H. Hendgrlg Codes. for Wastes Used Above <br />L: L. <br />" 04677- <br />1S. Sparest Handling Instructions and Additional Information <br />16. GENERATOR'S CERTIFICATION: I hereby certify tat the cements of this shipment are fully and accurately described and are in <br />in proper condition for tmnsporL The materials described on this manifest are not subject to federal hazardous waste regulations. <br />all respects <br />Date <br />- <br />Pdntedrrypsdgl — <br />Signature <br />Dery Year <br />T <br />17. Transporter 1 Acblowledgemerit of Recall of Mater H <br />Date <br />R <br />N <br />Pdnted/rY_PeejhQ�, oma r__ <br />Signature _ <br />�Mon� y` r <br />0 <br />18. Transporter 2 Acknoviledgement of Re ipt of Materials <br />IF <br />Date <br />TPdnted/Typed <br />Name <br />Signature <br />Moalh Day Year <br />E <br />R <br />. <br />Discrepancy, DiscrepanIntlkaton Space <br />- <br />A <br />C <br />1 <br />20. Facility pwner or Operator, Certification of receipt of the waste materials covera l by this manifest, except as noted In Item 19. <br />._ <br />I <br />-- <br />Date <br />T <br />Pdnt9d Typetl Name <br />Signature <br />Day' Y r <br />Y <br />!� <br />/ <br />_ / <br />CF14 02002 LASELAASTFA® gap) x213008 wwx.ldbelmaslaraem ..1� <br />�wmmp'Ni�Q[Dl�ka._ <br />VNNSOR.MM INK <br />LSI <br />