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W <br />N <br />?a <br />7 <br />IV) <br />D <br />0 <br />0 <br />a <br />N <br />Q <br />Z <br />O <br />Z <br />-NGN`AAZARDOUS WASTE MANIFL-6T <br />Please <br />print or type (Form designed for use on euro H[ <br />Peon) ryPewnen <br />2 <br />Paga1 <br />NON -HAZARDOUS <br />1. Genestors US EPA ID No. ° <br />_ 1 <br />paum MNo./ <br />WASTE MANIFEST <br />fr <br />( <br />d <br />l <br />Name <br />3. Genemtai's me and Melling Address /Ii Ly�',.C' /�- `�•; + <br />f. .: Y ; i "V {I.. <br />f �--� , <br />ky <br />4. ."i we <br />5. Transporter 1 O"FlY Nang j _ 8. <br />US EPA 10 Number <br />A State Transporter's ID <br />B. Transporter l Phone <br />` I I ":.. ( f i f: t '_./ f' l <br />• <br />7, Transporter 2 Company Name 8. <br />US EPA ID Number <br />C. State Transportefs ID <br />D. Transporter 2 Phone <br />9. Designated Facility Name and She Address W. <br />US EPA ID Number <br />E. State Facliy'a ID <br />F. Fadlltys Phone <br />11. WASTE DESCRIPTION <br />13.Total <br />Unit <br />Type <br />Quantity <br />Wt1Vd. <br />f12,ntainers <br />G <br />b. <br />E <br />N <br />E <br />R <br />e. <br />A <br />T <br />O <br />R <br />d. <br />G. Additional Descriptions for Matedals Listed Above <br />H. Handling Codes for Wasies Listed <br />Above <br />18. Special Handling Instructions and Additional Information <br />JW AW AW AW AW AW AW AW AW <br />AW AW AW AW AW <br />a <br />lfi. GF!lETUTORS CERTIFlCATION: I here%certiy that the contents d this shipment are fullyy and accurately described and are In <br />The Is described on this manifest are not subject to federal hazardous waste regulations. <br />all respects <br />in proper condition for trans poM1 Mass <br />Data <br />PrImedrTyped.Name <br />Signature F - J <br />Mond <br />Day <br />Year <br />fix: i i <br />T <br />17. Transporter 1 Acknowledgement of Receipt of Materlala <br />1 <br />Detal <br />R <br />A <br />PrinteMyped Name <br />Signature iJ' <br />Month <br />.,_Day <br />Year <br />p18. <br />Transporter 2 Acknowledgement of R 'p! of Materials <br />c F <br />Date <br />TPrinteMyped <br />Name <br />Signature <br />Mond <br />Day <br />Year <br />E <br />. <br />R <br />19. Discrepancy IMiradon Space <br />F <br />A <br />C <br />I <br />20. Fadly Owner or Operator; Certification of receipt W the waste materials covered by this manifest, except se holed in item 19- <br />L <br />Da e <br />T <br />Pdn.*j Yped Name <br />Signature <br />Month <br />. �Y j <br />Y <br />Y <br />CF14 02002 LAUUj, IASTFA® (9901621.5909 www.labaknmt-laom <br />�e" <br />