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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 /> p F ti: Document No. <br /> WASTE MANIFEST � �� v'- � of <br /> 3.Generator's Name and Mailing Address r <br /> x- Ftib 9t2Z #'sR-t IF`rs s"F dF r awn,t � u <br /> ?.•<'X'r.-b:, ,�Y .;.'3.. ":;�5,4u+11�. '.xr'k k't`. "° i4. $,.�2 h•R. y,. '{F*:d r'^.. i� <br /> h <br /> ".-�t�'tit Id din <br /> . ri,.ate Lsn a< <br /> K. <br /> 4.Generator's Phone <br /> 5.Transporter 1 Company Name 6. US EPA ID Number A.State Transporter's ID <br /> B.Transporter 1 Phone <br /> 7.Transporter 2 Company Name 8. US EPA ID Number C.State Transporter's ID <br /> D.Transporter 2 Phone <br /> 9.Designated Facility Name and Site Address 10. US EPA ID Number E.State Facility's ID <br /> p. <br /> 3 ..-',1`i9 111.. <br /> ar"i� 1 � z+;;r � '� <br /> I Ii 4A r s� .'� 4i. r.. ' 3.' L;s F.Facility's Phone <br /> F;,.x <br /> � :`? � <br /> 11.WASTE DESCRIPTION 12. Containers 13. 14. <br /> Total Unit <br /> No. Type Quantity Wt.Noi. <br /> a. +. V,0_4,,3x � 8 a�S,Y ,� -MK � a <br /> 12 v.p, f c x Yeti.}'* i° ..i" ��b�'.x .�y '•..'i c <br /> G b. <br /> E _ <br /> N <br /> E <br /> C. <br /> A <br /> T <br /> 0 <br /> R d. <br /> l- <br /> G.Additional Descriptions for Materials Listed Above H.Handling Codes for Wastes Listed Above <br /> Cni <br /> 0 <br /> _N, <br /> N 15.Special Handling Instructions and Additional Information <br /> 4 r .q1 3".�;ro�,+j+� 3. `'.V:l5 3 `$, f�d` T,•°^} �. tac,�" `=f F7' -. <br /> A <br /> it <br /> 7 r <br /> 1 ate ' 4 , <br /> Ev AV AW Aff AV AV AV AW AW AW AW AW, <br /> ANNR <br /> AM AM <br /> 16.GENERATOR'S CERTIFICATION:I herebycertifythat the contents of this shipment are full and accurate) described and are in all respects, . <br /> in proper condition for transport.The materils desribed on this manifest are not subject to federal hazardous waste regulations. <br /> P p p X.4 a <br /> Date <br /> .,.,,.. <br /> d/Typed Name Signatur Month Day Yr <br /> j, Yom, <br /> T 17.Transporter 1 Acknowledgement of Receipt of Materials "`" <br /> Date <br /> R <br /> A Printed/Typed Name Signature Month Day Year <br /> N <br /> 0 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 <br /> I Date <br /> "T' Printed/Typed Name Signature Month Day ,.-Year <br /> y <br /> CF14 ©2002 LASEAASTE1t® (800)621-5808 www.labelmaster.corn PRINTED ON RECYCLED PAPER ,Rlgi(o WIiM <br /> USING SOYBEAN INK <br />