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N( -HAZARDOUS WASTE MAP =ST <br /> Please print or type (Form designed for use on elite(12 pitch)typewriter) <br /> NON-HAZARDOUS 1.Generator's US EPA ID No. Manifest 2.Page 1 <br /> Document No. <br /> WASTE MANIFEST It. ' o, <br /> 3.Generator's Name and Mailing Address <br /> -..'.L0717if-_tag Slati0; <br /> "73a'azaI,. <br /> 4.Generator's Phone( ) _. _,t':4 ~VS <br /> 5.Transporter 1 Company Narrie 6. US EPA ID Number A.State Transporter's ID <br /> B.Transporter 1 Phone <br /> 7.Transporter 2 Company Name 8. US EPA ID Number C.State Transporter's ID <br /> D.Transporter 2 Phone <br /> 9.Designated Facility Name and Site Address 10. US EPA ID Number E.State Facility's ID <br /> :E.-0,7y- <br /> . •:1;.: 1- ,',�' .=��.: F.r; F.Facility's Phone <br /> 11.WASTE DESCRIPTION 12. Containers 13. 14. <br /> Total Unit <br /> No. Type Quantity Wt.Ncl. <br /> a. <br /> i S <br /> G b. <br /> E <br /> N <br /> E <br /> R C. <br /> A <br /> T <br /> O <br /> UJ R d. <br /> G.Additional Descriptions for Materials Listed Above H.Handling Codes for Wastes Listed Above <br /> D <br /> a <br /> 0 ` <br /> a . <br /> Q15.Special Handling Instructions and Additional Information <br /> r <br /> Z <br /> Z <br /> 6ArWAVAVAVM"MMMMMMMWAW <br /> 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 transport.The materials described on this manifest are not subject to federal hazardous waste regulations. <br /> Date <br /> Printedlryped Name Signature Month Day Year <br /> T 17.Transporter 1 Acknowledgement of Receipt of Materials Date <br /> R <br /> A Printed/Typed Name Signature Month Day Year <br /> N <br /> P, 18.Transporter 2 Acknowledgement of Receipt of Materials 6ate <br /> RPrinted/T d Name Signature Month Da <br /> T Printed/Typed 9 Y Year <br /> E <br /> R <br /> 19.Discrepancy Indication Space <br /> F <br /> 1 <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 <br /> Date <br /> T Printed/Typed Name Signature Month Day Year <br /> Y <br /> -r1 2002 LASELAASTFR® (800)621.5808 www.labelmastercom <br />