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1 <br /> 1. Ger+ at rs 5 EPA ID No. Manifest 2. Page 1 <br /> NON-HAZARDOUS Document No. of <br /> WASTE MANIFEST <br /> 3. Qe�nerotor's Name and ailing Address / <br /> 03 r <br /> 4.. Generator's Phone U ) ; <br /> 5. Tran 1 Compan a b. US EPA ID Number <br /> N <br /> 7. ronsporter 2 Company Name 8. US EPA 1D Number <br /> ' <br /> A. Transporter's Phone <br /> 9. D si n d F°�ility Name,and Site Address �' 10. US EPA ID Number II <br /> B. 7ronsporter's Phone 1 <br /> l(/b41 C.�7Fac�ility's Phone <br /> 12. Containers 13. 14. <br /> 11. Waste Shipping Name and Description Total Unit <br /> No. Type Quantity Wt Vol <br /> 1 _ <br /> G b. . <br /> N <br /> E <br /> R i <br /> I A c. <br /> T <br /> O <br /> R <br /> d <br /> D. Additional Descriptions for Materials Listed Above E. Handling Codes'for Wastes listed Above <br /> Tars <br /> tilof-Pr ae4 ik6i-� GV,7Y- <br /> 15. Special Handling Instructions and Additional Information <br /> is <br /> . <br /> 16.GENERATOR'S CERTIFICATION: I certify the materials described above on this man fest are not abject to lederol regulations#a reponinp proper disposal of Hazardous Woste. <br /> Printed/Typed Name__, - Signature Az� <br /> Month Day Yeor <br /> /apy> �.Lo� �_ /z l <br /> T 17.Transporter 1 Acknowledgerng4t cy Receipt of Materials <br /> R <br /> Printed/Ty¢ed Name Si Month Year <br /> N pO1.3 <br /> S <br /> P <br /> O 18.Transporter 2 Ackno dg ent of Receipt of Materials <br /> TPrinted/Typed No Signature Month par` Year <br /> 19.Discrepancy Indication Space <br /> f. A . <br /> C <br /> t l 20.Facility Owner or Operator.Certification of receipt of waste materials covered by this manifest c pt as noted in Item 19. = : <br /> T <br /> Y <br /> Printed/Ty d Name Signature Month Aar Yeor <br /> � f1 <br /> ORIGINAL-RETURN TO GENERATOR <br />