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NON-.HAZARDOUS WASTE MANIFEST
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<br /> ® 1 Generator's US EPA ID No Manifest 2.Page 1
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<br /> Document
<br /> WASTE MANIFEST
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<br /> 3 Generator's Name and Mailing Address
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<br /> 4.Generator's Phone(- '3 Kx ik k
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<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 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
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<br /> .� "' x' F.Facility's Phoney
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<br /> 11.WASTE DESCRIPTION 12. Containers 13. 14.
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<br /> G.Additional Descriptions for Materials Listed Above H.Handling Codes for Wastes Listed Above
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<br /> N 15.Special Handling Instructions and Additional Information
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<br /> 16.GENERATORS 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 aste regulations..;-„t,�.,r,,,,
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<br /> T 17.Transporter 1 Acknowledgement of Receipt of Materials Date
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<br /> A Printed/Typed Name Signature Month Day Year
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<br /> O 18.Transporter 2 Acknowledgement of Receipt of Materials Date
<br /> R Printed/Typed ed Name Signature
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<br /> 19.Discrepancy Indication Space
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<br /> 1 20.Facility Owner or Operator;Certification of receipt of the waste materials covered by this manifest,except as noted in item 19.
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<br /> Date
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<br /> CR4 ©2002 LABEI.MASTE.It® (800)621-5808.www.labelmaster.com PRINTED ON RECYCLED IIINTED WIIN
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