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' N%-.4-HAZARDOUS WASTE MAI--...=EST <br /> P,(ease print or.type (Form designed for use on elite(12 pitcli)typewriter) <br /> abiNON-HAZARDOUS©QUS 1.Generator's US EPA ID No. Manifest 2.Page 1 <br /> ' Document No. <br /> WASTE MANIFEST °' 1 <br /> 3,Generator's Name and Mailing Address <br /> 4.Generator's Phone( ) _, f,,.•-r r iY•• (..i <br /> S.Transporter 1 Company Nama 6. US EPA ID Number A.State Transporters ID <br /> B.Transporter I Phone <br /> ' 7.Transporter 2 Comparrl Name S. US EPA ID Number C.Stale Transporters ID <br /> D.Transporter 2 Phone <br /> 9.Designated Facility Name and Site Address 10_ US EPA 10 Number E.State Facility's 10 <br /> YrxxY �flwki <br /> it <br /> 1 i�:11 0,4T , F_Faoilityjs Phone , <br /> ' 11.WASTE DESCRIPTION 12. Conlairters 13. 14. <br /> Total Unit <br /> No. Type Quanlity WiNal. <br /> a. LL <br /> ' J i)i 5 r"{ cl _ ;'' (.:rv���i.fi�: �:�T• {'..t CLL Ltilj:�f i. <br /> G b. <br /> E <br /> E <br /> E <br /> R c• <br /> A <br /> T <br /> ' O <br /> W <br /> R d. <br /> t/7 <br /> G.Additional Descriptions for Materials Listed Above H.Handling Codes for Wastes Listed Above <br /> ' o <br /> v <br /> a <br /> Q15.Special Handling Instructions and Additional information <br /> t <br /> z <br /> 0 <br /> ' z <br /> 15.GENERATOR'S CERTIFICATION:l hereby certify that the contents of this shipment are fully and accurately described and are in all respects <br /> in proper condition for 1(anspod.The matenals described on this manifest are not subject to federal hazardous waste regulations. <br /> ' Date <br /> PrintedlTyped Name Signature Month Day Year <br /> ' T 17-Transporter 1 Acknowledgement of Receipt of Materials Date <br /> R <br /> A Printed'TypedName r r. f Signature !�f Jfi Monrh bay Year. <br /> $ ��•1:tel.;'L t' �'l?.:it � ', ` ! �' Y <br /> O18.Transporter 2 Acknowledgement of Receipt of Materials Date <br /> ' T Prinled/Typed Name Signature fRonUt Day Year <br /> E <br /> R <br /> ' 19.Discrepancy Indication Space <br /> F <br /> A <br /> C <br /> 20.Facility par.^,er or Operator,Certification of receipt of the waste materials covered by this manifest,except as noted Ln item 19. <br /> ' ; Dale <br /> T PrinledrTyped NameSignah re r ATionlh tDay Year <br /> Y �L�lf(,l rt�=� �'1�y F{�f.1 } <br /> ' F-14 02002 LADCAA5TERm (600)521-5808 vmm.labalmaster.comacnomtn Rev.3'95 <br /> �l SOY INK <br />