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Ir�it( <br /> NON-HAZARDOUS I Generator's US EPA ID No Manifest 2 Page 1 4Taf„r� D N t" <br /> WASTE MANIFEST A L d 0 0 o 4 3 3 A* �o,trment�Na of 13 Z 1/ 7+ -b'z c(4 <br /> 3 Generators Name and Mailing Address a v i k STr>p M� e rs (J 04, �/ 1 <br /> Q0 'S�45 re4l5,,t7t`1-r, caGi4S37 l 71 <br /> 4 Generator's Phone(�EQ �oS Z-$r7�0 4c5&7 <br /> 5 Transporter 1 Company Name G US EPA ID Number <br /> .rGFG�o�J C. AJDO0414 (V & 39 <br /> 7 Transporter 2 Company Name 8 US EPA ID Number r <br /> 9 Designated Foam4y Name and Site Address 10 US EPA ID Number A Transporters Phone 10 I <br /> 41 (tea fr..I o t V <br /> B Transporters Phone <br /> fl(.►�a�� F <br /> c 1 e1'�1i1 e A 0 0 4` 3' 2 �G Q 7 Q �S aeslt 's Phone �— I <br /> 11 Waste Shipping Name and Descnption 'TK 12 Containers 13 14 <br /> Total Urnt <br /> No Type Quanta Wt Vol <br /> a <br /> ?0 77 X) 61A <br /> E b <br /> E <br /> N <br /> E <br /> R <br /> A c <br /> T <br /> 0 <br /> R <br /> d <br /> D Additional Descriptions for Materials Listed Above E Handling Codes for Wastes Listed Above <br /> 15 Special Handling instructions and Additional Information <br /> 16 GENERATOR'S CERTIFICATION I certify the materials liescribed above on this manifest are not subtest to federal regulations for reporting Proper disposal of Harordous Waste <br /> Printed/Typed Name r Signature ,y Month Day Year <br /> R17 Transporter 1 Acknowledgement of Receipt of Materials <br /> N P Hied T m Sig tur Month Day year <br /> S <br /> dFrP <br /> O 18 Transporter 2 Acknowledgement of Receipt of Materials <br /> R <br /> EPrinted/Typed Nome Signature Month Day Year <br /> R / <br /> 1L. 19 Discrepancy Indication Space <br /> 20 Focilay Owner or Operator Certification of receipt of waste materials covered by this manifest except as noted in Item 19 <br /> Printed/Typed Name Signature Month Day Year <br /> GENERATOR'S COPY <br />