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NON-HAZARDOUS, WASTE MANIFEST <br /> Please print or type (Form designed,for use on elite:(12 pitch)typewriter} <br /> ,; 1.Generator's US EPA ID No. Manifest 2.Page 1 <br /> NON <br /> Document No. <br /> ' D .. of <br /> WASTE MANIFEST. <br /> 3.Generator's Name and Mailing Address <br /> C 1 7 <br /> EMPITIC GAS +' C Co. 'TRACT SM,I(Ar <br /> 2 <br /> 19. T . <br /> A CA T .95376 <br /> 4.Generators Phone( .,��" <br /> 5.Transporter 1 Company Name 6. US EPA ID Number A.State Transporter's ID <br /> ` - B.Transporter 1 Phone <br /> 7.Transporter 2 ompany 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 /> A � � � <br /> , �1q F.Facility's Phone <br /> 6349 9490 aCA <br /> ' . 4 - <br /> 11.WASTE DESCRIPTION 12. Containers 13. 14. <br /> Total Unit <br /> No. Type Quantity Wt.Nol. <br /> a. <br /> NOR REMAM MISRIAL (KON HAW4.01S JIL) <br /> G b' 1 <br /> N <br /> E . <br /> R c. <br /> A <br /> T <br /> R d. <br /> H <br /> G.Additional Descriptions for Materials Listed Above H.Handling Codes for Wastes Listed Above <br /> 11a, 10-2310CA, NOM HA tk'RMTJ8! 8011 <br /> I <br /> — 0 , <br /> QI Id <br /> a <br /> ' 15 Sgecial Handling Instructions and Additional Information <br /> NG & xy <br /> UR24 IMON A <br /> AV AW AW AV <br /> AW M <br /> AW. AM, AV AV AW AW.AW AV AM <br /> 16.GENERATOR'S CERTIFICATION:I hereby certify that the contents of this shipment are fully and accurately de ibed-and are in all respects <br /> in proper'condition for transport.The materials described on this manifest are not subject to federal hazardous aste'regulations. <br /> Date <br /> 1n d!T yp e a Signature Month Day Yea <br /> j}N <br /> .K Y <br /> ta <br /> T 17.Transporter 1 Acknowledgement of Receipt of Materials Date <br /> R Da Month� <br /> A Prir�tted/Typed Name �,,,�w,; Signature �� _ � Y Year <br /> Z, <br /> Nr1% <br /> p�I c . d� �NI --I <br /> 2ki (282 <br /> O 18.Transporter 2 Acknowledgement of Receipt of Materials �° Date <br /> R Printed/Typed Name Signature Month Day Year <br /> T <br /> E <br /> R , <br /> 19.Discrepancy Indication Space <br /> F <br /> A <br /> C <br /> 20.Facility Owner or Operator;Certification of receipt of the waste materials covered by this manifest,except as noted in item 19. <br /> Date <br /> Printed/Typed Name Signature Month Day Year <br /> Y <br /> ® PRINTED ON RECYCLED PAPER r f111NTE0 WITH <br /> CF14 02002 LABEAASTE t O (800)621-5808.www.labelmaster.com USING SOYMAN IW I SdY�NK <br />