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N <br />0 <br />0 <br />N <br />Q <br />Z <br />Z <br />NON -HAZARDOUS WASTE MA IF <br />Please print or typo (Form designed Ior use en altie ( 12 pitch; lypawriter) <br />GP14 02002 kv <br />NON -HAZARDOUS <br />i. Gonerator's US EPA (D Nri. <br />Manifest <br />2. <br />Paga t <br />WASTE MANIFEST' <br />ts�i441t+°} <br />Document No. "YiSjt,tl <br />of <br />3. Generators Name and Mailing Address <br />Pod of t triddrmt <br />�f !11't lNf:dP linfl(w Avwn r <br />:todzte;it) cAo,52.0I <br />ff <br />t <br />d. Genemtoes Phone <br />5. Transporter 1 Company Name 8. <br />US EPA ID Number <br />A, Stale Transporters ID <br />,'f�,?Itl^3Sia r.(tt=hitt_'=2(!'a3Yr(�stt:tf;.;i <br />4.•';'.j(�(i.:7((`.` vQ} <br />B. Transporter t Phone <br />7 Transporter 2 Company flame 11. <br />US EPA 10 Number <br />C Stale Transporters 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 />%rtf Fr itr tS f_`,'ii:2el`s#r:f ° 3alr:s 4:aa11 u�c Pat! <br />s115 <br />F- Facifity's Phone <br />11 WASTE DESCRIPTION <br />Containers <br />13. <br />14. <br />Total <br />Unit <br />No. <br />Type <br />Quantity <br />WI.No1. <br />G <br />b. <br />E <br />N <br />E <br />R <br />a. <br />A <br />T <br />0 <br />R <br />d. <br />G. Additional Descriptions for Malenals Listen Above <br />H. Handling Codas for Wastes Listed Above <br />( IFftaSttf; ,, <br />- <br />15 Special Handling Instructions and Additional Inlormatbn <br />M <br />16. GENERATOR'S CERTIFICATION: thereby certify that the contents of this shipment <br />are full yy tend accurately <br />described and are <br />in all respects <br />in proper condition for transport. The materials described an this ntamfest are not subject to federal hazardous taasto regulations. <br />t <br />Date <br />PrinterLTypedName <br />SfynalUro <br />�.ty <br />Ifil <br />Month <br />Day Year <br />- <br />4. <br />T <br />17. Transporter 1 Acknowledgement of Receipt of Materials <br />Date <br />APrintediTypod. <br />Name <br />Signatute <br />.r' <br />Month <br />Day Year <br />N <br />_ <br />r <br />- <br />0 <br />18. Transporter 2 Acknal:ledgemGnt of Receipt of Materials <br />Date <br />R <br />T <br />Ptinlocirryped flame <br />alure <br />Month <br />Day Year <br />E <br />R <br />19 Discrepancy Indication Spaeo <br />F <br />A <br />C <br />20 Facility Qwnar at Qperitor: Certlficallen of receipt of the waste materials coveted by <br />this manifest, except as <br />noted in dont 19. <br />L' <br />Date <br />TPrinlodr?yped <br />Name <br />Signature <br />Month <br />Day Year <br />Y <br />f.AIIELMASTERd (800) 621-5808 wwvr.lab0lmasteccom <br />.•: y,ccn.Xncrn MK'n IC�1 Y'+iiisMK <br />