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oraroe ara8ts <br /> NON-HAZARDOUS 1 Generators US EPA ID No Manl�tesDoc No a�g 1 <br /> WASTE MANIFEST V I��C> <br /> 3 Generators Name and Mailing Ad ss <br /> 4 Generators Phone <br /> 5 Trans rter 1 Company Name 6 US EPA ID Number A Transporter's Phone <br /> `1( 25;?13 <br /> 7 Transporter 2 Company Name 8 US EPA ID Number B Transporter's Phone <br /> 9 Designated Facility Name and Site Address 10 US EPA ID Number C Facility s Phone <br /> � U <br /> LI-C__ n? :—> <br /> 12 Con �+ 13 14 <br /> 11 Waste Shipping Name and Description Total Unit <br /> No Type Ouanuty Wt/vol <br /> G b <br /> E <br /> N <br /> E <br /> R <br /> A c <br /> T <br /> O <br /> R <br /> d a <br /> L.. <br /> N <br /> ddnional Descriptions for Materials Listed Above E Handling Codes for Wastes Listed Above <br /> 15 Special Handling Instructions and Additional Informat on <br /> r �At <br /> =1 <br /> i� <br /> r] a <br /> 16 GENERATORS CERTIFICATION. Me materials described above on this manifest are not sub o fe eral eg 8;+ for reporting proper disposal of Hazardous Waste r` <br /> ed Nam re Enth Day Year F <br /> E TR 17 Transporter 1 cknowledgement of Receipt of Materials <br /> i A Pr edrT ped Name Signature art <br /> N L� <br /> 5 <br /> P <br /> ti R 18 Transporter Acknow dgement f Receipt of Materials <br /> % <br /> T Printed/Typed Name Signature _ Month Day Year <br /> E "e <br /> R <br /> 19 Discrepancy indication Space <br /> F <br /> A _ <br /> G <br /> I <br /> l 0 Facility Owner or Operator Cenification of receipt of waste materials covered by this manifest except as noted in Item 19 <br /> E <br />' Y Printed/Typed Name Signature Month Day Year <br /> Printed by J J KELLER 8 ASSOCIATES INC 12-BLS-05 Rev 12/98 <br /> Neenah WI 54957 036a <br /> ORIGINAL- RETURN TO GENERATOR <br />