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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 /> T <br /> NON® F �. x z Document No. 0 <br /> ANTE . .., r: `. of <br /> 3.Generator's Name and Mailing Address <br /> tr }:c fir. <br /> 4.Generator's Phone(s> �` g 4 <br /> 5.Transporter 1 Company Name 6. US EPA ID Number A.State. ransporter's!D <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 /> eAi <br /> SA <br /> F.Facility's hone t r r <br /> 41 <br /> 11.WASTE DESCRIPTION 12. Containers 13. 14. <br /> Total Unit <br /> No. Type Quantity Wt.Nol. <br /> a. <br /> �a=. Yc .`'� 7•,.�� �t� '�c '� J'i? '�..3a�..'�'.� �.� ��.`.?3K y y <br /> �k' <br /> G b. <br /> E <br /> N <br /> E <br /> R c. <br /> A <br /> T' <br /> a - <br /> R d. .. <br /> tn <br /> G.Additional Descriptions for Materials Listed Above H.Handling Codes for Wastes Listed Above <br /> .ry', ¢ sz.r J,'...•,q .:..% a�: Wl a_54 ..r. F..Vi !...ek. aCn <br /> �.. <br /> 0 <br /> yt <br /> 15.Special Handling Instructions and Additional Information <br /> i2 ux'.iJ7�.��;'.�}��j^i. ,,rf y�qn y Q Y��,t���s✓���y' <br /> V f:+y' <br /> 41,1 <br /> AEF AM <br /> AW AAW Aff Aff Aff AW AW AV AW <br /> j.. <br /> R . <br /> 16.GENERATOR'S CERTIFICATION:I hereby certify that the contents of this shipment are fully and accurateI described and a e ih all respects G', <br /> in proper condition for transport.The materials described on this manifest are not subject to fed e I hazards waste regulaws. <br /> AX�y Date <br /> n <br /> /Typed Name �,. Sig ure } r. t o th 7a Year <br /> IFO Y.. <br /> T 17.Transporter 1 Acknowledgement of Receipt of Materials Date <br /> RSi nature Month Day Year <br /> A Printed/Typed Name g <br /> N .. - <br /> P <br /> ® 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 /> L Date <br /> 1 <br /> T Printed/Typed Name Signature Month Day Year <br /> 14 C ♦ PRINTED ON RECYCLED PAPER <br /> CFPAINTED WITH <br /> f- 2002 �.A�LM/1STFR® (800)621-5808 www.labelmaster.com uSING SOYBEAN INK <br />