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NON-HAZAJS WASTE MANIFEST <br /> Please print or type (Form designed for use on elite 112 pitch)typewriter) <br /> NONLHAZARDOUS 1.Generator's US EPA ID No. Manifest 2.Page 1 <br /> WASTE MANIFEST Document No. <br /> of <br /> 3.Generator's Name and Mailing Address <br /> 4.Generator's Phone( ) <br /> 5 Transporter 1 Company Name 6. US EPA ID Number A.State Transporter's ID <br /> a t, 'r'--- - - B.Transporter 1 Phone <br /> 7.Tmnnporler 2 Company Name 8. US EPA ID Number C.State Transporter's ID <br /> D.Transporter 2 Phone <br /> 9.Designated Facility Name and Site Address 10. US EPA ID Number E.Stale Facility's ID <br /> F.Facility's Phone <br /> 1 .WASTE DESCRIPTInN Containers 13. 14 <br /> Total Unit <br /> No. Type Quantity Wt.Nol. <br /> G b }J <br /> E <br /> N <br /> E <br /> R <br /> A <br /> T <br /> O <br /> R d. <br /> LU <br /> NG.Additional Descriplions for Materials Listed Above H.Handling Codes for Wastes Listed Above <br /> a <br /> P ) H(qe <br /> c 15.Special Handling Instructions and Additional Information <br /> 4 ) 62U ;ki Lam.- - TRU- nD I % iSa"� <br /> _ I ro)er,t Mur-bet: (rii)V729-04 <br /> Z <br /> Z <br /> 16.GENERATOR'S CERTIFICATION:I hereby rerlHy that the contents of this shipment are fully and accurately described and are in all respects <br /> in proper condition for transport.The materials described on this manifest are not subject to federal hazardous waste regulations. <br /> Date <br /> Printed/Typed Name Signature Month Day Year <br /> T 17. Transporter 1 Acknowledgement of Receipt of Materials Date <br /> R <br /> A PrintedrTyped Name Signature Month Day Year <br /> IN <br /> S <br /> P <br /> 0 1 B. Transporter 2 Acknowledgement of Receipt of Materials Date <br /> R PrinteNTyped Name Signature Month Day Year <br /> E <br /> R <br /> F 19.Discrepancy Indication Space <br /> A <br /> C <br /> L 20.Facility Owner or Operator:Certification of receipt of the waste materials covered by this manifest,except as noted in item 19. <br /> I Date <br /> T Printed/Typed Name f3lgna[We Month Day Year <br /> Y <br /> CF14 192002 LABELI$IASTER® (800)621-5808 www.labelmaster.com <br />