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oiipi� - is <br /> NON-HAZARDOUS1. Generator's EPA ID No. Manifest Doc.No. 2. Page 1 <br />' WASTE MANIFEST <br /> � <br /> 3. G r�ra i almaan�ailL'Tddre!? <br /> 4. Generator's Phone{ } <br /> ��� <br /> 1 Cgnlpa>�y N me,7� 6. US EPA ID Number A. Transporter's Phone T <br /> rYG�'f,�r`/,1 �! vn r �Y �. , �CJ <br /> ' 7. Transporter 2 Company Name 8, US EPA ID Number B. Transporters Phone <br /> 9�_�II 5�=LL ,lto`�Facility Name and Site Address 10. US EPA ID Number C. Facility's Phone <br /> ii efj- <br /> Lai n e 1►-, . er.� - - �_ ! -z� <br /> 11,Waste Shipping Name and Description 12. Containers 13. 14. <br /> Total Unit <br /> No. I Type Quantity WtfVol <br /> a. <br /> G b. <br /> E <br /> N <br /> E <br /> Ia <br /> A c. <br /> = T <br /> 0 <br /> R <br /> d. o- <br /> - rr <br /> itional escriptions for Materials Listed Above E. Handling Codes for Wastes Listed Above ' <br /> Co <br /> t �j <br /> 15.Special Handling Instructions and Additional Information t <br /> .44 <br /> �Sfrffq <br /> 3 <br /> Y <br /> � .pM <br /> 15.GENERATOR'S CERTIFICATION; I Certify the materials described above on this manifest are not subject to federal r QUIBri s Ic r onin .proper disposal of Hazardous Waste. <br /> In(edlTyped Name i f Monfb Oay Year ?! <br /> if <br /> 111+ 1 1 _ J <br /> T 17.Transporter 1 tcknowledgement of Receipt of Materials <br /> R t' ; <br /> 5 Pr'r dlTyped NameI Signa Monrn nay Year <br /> ' L• r <br /> P "z <br /> R 1$.Transporter 2 Acknowledgement of R eipt of Materials <br /> ;w« <br /> EPrinted(Fyped Name Signature Month Day Year ." <br /> 19. Discrepancy Indication Space p <br /> !" F <br /> C <br /> Facility Owner or Operator:Certification of receipt of waste materials covered by this manifest except as noted in Item 19. <br /> ' Y <br /> Printed/Typed Name Signature Month Day Year <br /> Printed by J.J.KELLER&ASSOCIATES,INC. + - <br /> j 12-BLS-05 Rev. 12198 <br /> ' Neenah,wlsass�asss�.`� „ Y : _. ORIGINAL— RETURN TO GENERATOR <br />