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NON-HAZARDOUS 1 Generator s US EPA ID No Martrtest Doc No 2ge 1 <br /> WASTE MANIFEST "' <br /> 3 Generators Name and Mailing Add <br /> (,,,` a-�-� 5�,les <br /> -Z 25'? <br /> 4 Generator s Phone{ } �/� at 7 <br /> 5 a o�_e, !�� <br /> � y Nams 5 US EP 1D Number A Transporters Pho <br /> r -: (r <br /> E 7 Transporter 2 Company Name 6 U5 EPA ID Number B Transporters Phone <br /> I 9 Designated Facility Name and Site Address 10 US EPA ID Number C Faclhtys Phone <br /> 44,ea o7 c.,, Jr,11I <br /> kt f paz <br /> 12 Containers 13 14 <br /> I11 Waste Shipping Name and Description Total Unit <br /> I{ No I Type Quantity WWol <br /> r <br /> :54roSo d <br /> G b <br /> E 1 <br /> I N <br /> ` R <br /> A c <br /> T <br /> O <br /> t R d *mss <br /> i <br /> W <br /> ID dda onal Descriptions for Materials Listed Above E Handling Codes for Wastes Listed Above �r <br /> c <br /> 15 Special Handling Instructions and Additional Information <br /> I * , <br /> I � , <br /> E <br /> { 16 GENERATOR S CERTIFICATIO I%%erj,ty the rra,erials described above on this mandest ase not subject to fe ral regulations for reposing proper disposal of Hazardous Waste <br /> 5 <br /> I Print ped Name, r <br /> Month Day Year ; <br /> T 17 Transporter 1 hcknoAledgement of Receipt of Materials <br /> A Pr ted/T ped Name 5i 'jure r{ti/ DFiy e r <br /> 5 <br /> G" P <br /> O 18 Transporter 2 ckno ledgemert of Receipt of Materials <br /> R Si nature Month Day Year <br /> r T Printed/Typed Name <br /> E <br /> R <br /> j19 Discrepancy Indication Space <br /> T F <br /> 1 C - <br /> r <br /> I <br /> 20 Facility Owner or Operator Certification of receipt of waste materials covered by this manifest except as noted in Item 19 <br /> ' Y PriniedlTyped Name Signature Monih Day Yaar _ <br /> t <br /> I Printed by J J KELLER&ASSOCIATES INC 12-BLS-05 Rev 121/98 <br /> Neenah W154957-0368 ORIGINAL- RETURN TO GENERATOR <br />