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' NON-HAZARDOUS WASTE MANIFEST <br /> please-print or type (Form designed for use on elite(12 pitch)typewriter) 2.pav.1 <br /> HON-HAZARDOUS <br /> 1.Gene manifest g <br /> ' Document No. <br /> of <br /> WASTE MANIFEST �. <br /> 3.Generator's Name and Mailing Address �r�qt{ ,r � (^' <br /> -, <br /> h.Generators Phone <br /> 5.Transporter t Company Name 6, US EPA ID Number A State Transporttes,td <br /> t B,Transporter 1 Phone <br /> 7.Transporter 2 Company Name e. US EPA ID Number C.State Transportees ID <br /> D.Transporter 2 Phone <br /> 9.Designated Facility Name and Site Address 10. US EPA ID Number E.State FadA'ty's ID <br /> *Vr_ -x F,Facility's Phone <br /> S f2. Containers 13. 1 <br /> 4. <br /> 11.WASTE DESCRIPTION Total Unit <br /> No. Type Quantity 1Aff.Na1. <br /> a. <br /> biCt <br /> .t <br /> G b <br /> E <br /> N <br /> E <br /> R C. <br /> A <br /> ' T <br /> Q <br /> R d. <br /> W <br /> G.Additional Descriptions for Materials Listed Above H.Handling Codes for Wastes Listed Above <br /> 1 <br /> ' 15.Special Handling Instructions and Additional Information <br /> a <br /> z <br /> AU AW AV AW MAK AWAW ME Aff AV NFAV AV Ms <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 /> t in proper condition for transport.The matensis described on this manifest are not sub;ect to federal hazardous waste,regulations. <br /> Date <br /> Printedfryped Name Signature Month Day Year <br /> tT� 17.Transporter 1 Ackr1 W'lsdgomsnl of Receipt of Materials Date <br /> A Pfirl�edd'ffTyped Name s, 1 t 1 t Signature}f J/ tdoCnttr Day Y <br /> t O 18.frraansporier 2 Acknowledgement of Receipt of Miatefrals Data <br /> TPrirtedfTyped Name Signature Month Day Year <br /> E <br /> ' R <br /> 19.Discrepancy Indication Space <br /> F <br /> A <br /> C <br /> t 20.Facility Owner orOperator,Certification of recolpt of the waste materials covered by this manifest,except as noted in item 19. <br /> I <br /> i Date <br /> T Pdntedifyped Name Signature r. Month Day year <br /> ' F-td 02002 L10EL0IASTER0 (800)627-5806 www.Iabelmesteroom r�t;— Rev.$185 <br />