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W <br />I -- <br />En <br />4 <br />U) <br />M <br />O <br />Ca <br />cc <br />a <br />N <br />4 <br />S <br />Z <br />Z <br />NON -HAZARDOUS <br />Please print or typo (Form designed ter use on erste (t2 pitch) typowdter, <br />WASTE MANIFEST <br />CFtA 02002 LABELTNIASTERm (800) 625.5808 tivtvW.labelmasier,cont <br />Mao c+rr:ma•s•rr .gas—�^ <br />�i .< xaee+eswn< ( SgYINH <br />NON -HAZARDOUS 1. Generator's US EPA IDNo. <br />Manifest <br />2, <br />Page 1 <br />WASTE MANIFEST '1`t4.t_1Uf1U ►1 <br />Document No. <br />} {�> ,} <br />of <br />3. Generator's Name and Mailing Address <br />Poo orst clam <br />. <br />�i+y�� Hh�i�c 14P�y}Ct'!;:• <br />�•'"�'• <br />j1�11�ti+i <br />1i <br />.iiixC�;ILi(i, tfifi✓lr`3�S,y� f <br />4. Generatoes Phone( <br />5.7ransporter 1 Company Name 6. <br />U5 EPA id Number <br />A. State Transponet's <br />ID <br />; lfti6ifte�l r��ti!SYf > :=f' ifi�iq 1r3i# Iilfs. ��: ] <br />L { �'{{ { }{jA1 40 <br />8. Transporter t Phone 40t4• i <br />Ili V <br />7. Transporter 2 Company Name 8. <br />US EPA ID Number <br />C. State Transporter's <br />ID <br />D, Transporter 2 Phone <br />9. Designated Facility Name and Site Address 10, <br />US EPA iD Number <br />E. State Facility's ID <br />i,2 1!l?9rJdf { f5ffiif}{iit <br />GAL0003907i J <br />} <br />21 ,139 i {ZSit ti <br />~� <br />F. Facility's Phone <br />L;(9a3x#rGr�-tt�:�r C:/taL��:i��f} <br />?:��}—���i•'s�3� t <br />11. WASTE DESCRIPTION <br />Containers <br />13. <br />14. <br />_ <br />Total <br />Unit <br />No. <br />Type <br />Quantity <br />Wt-Noi. <br />y S <br />7t y �e.�S{1� g t(�� tt'-^rrp f( A ppry' S01, <br />hh ��.,,,-}p,,�r HAZARDOUS <br />G <br />b. <br />E <br />N <br />E <br />R <br />e <br />A <br />T <br />a <br />R <br />d. <br />G. Additional Descriptions for Materials Listed Above <br />H. Handling Codes for Wastes Listed Above <br />15. Special Handling Instructions and Additional Information <br />M <br />16. GENERATOR'S CERTIFICATION: i hereby certify that the contents of this shipment <br />are fullyy and accurately described and are in all respects <br />in proper condition for transport, The materials described on this manifest are not subject <br />to federal hazardous waste regulations. <br />Date <br />Printedll'yped IN, <br />Sigonture <br />Month <br />Day Year <br />T <br />17. Transporter 1 Acknowtedgemont of Receipt of Matorals <br />Date <br />APrintad?yped <br />Name <br />Signature <br />Month <br />Day Year <br />0 <br />18. Transporter 2 Acknowledgement of Receipt of Materials <br />Date <br />T <br />Printed.[Typed Name <br />Signature <br />Month <br />Day Year <br />E <br />R <br />19. Discrepancy indication Space <br />F <br />A <br />C <br />120, <br />Facility Owner or Operator: Certification of receipt of the waste materials covered by <br />this manifest, except as noted in item 19. <br />) <br />Date <br />j <br />Pdmedriyped Name <br />Signature <br />Month <br />Day Year <br />Y <br />CFtA 02002 LABELTNIASTERm (800) 625.5808 tivtvW.labelmasier,cont <br />Mao c+rr:ma•s•rr .gas—�^ <br />�i .< xaee+eswn< ( SgYINH <br />