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W <br />H <br />tR <br />Q <br />U) <br />0 <br />0 <br />cc <br />Q <br />N <br />Q <br />Z <br />0 <br />z <br />NON -HAZARDOUS WASTE MANIFEST <br />PlOase Orin( or 1VDa (Form (as ane for use on elite (12 r) c 1 View or <br />F14 Ca 2002 LABCLMASTF.R0 (800) <br />NONHAZARDOUS <br />1. Generator's <br />US EPA ID No. <br />Manifest <br />2. <br />Page i <br />Document Na, <br />WASTE MANIFEST <br />of <br />a. Generators Name and Mailing Address <br />4. Generators Phone { j <br />5. Transporter 1 Company Name <br />G. <br />US EPA ID Number <br />A. Stale Ttansponer's ID <br />B. Transporter I Phone <br />7. Transporter 2 Company Name <br />6. <br />US EPA ID Number <br />C. State Tiansporter's ID <br />D. Transporter 2 Phone <br />9. Designated Facility Name and Site Address <br />10. <br />US EPA ID Number <br />E. State Facility's ID <br />F. Facility's Phone <br />11. WASTE DESCRIPTION <br />12 Containers <br />13 -Total <br />14, <br />Unit <br />No. Type <br />Quantity <br />NR./VOI. <br />a. <br />G <br />a. <br />E <br />N <br />E <br />R <br />A <br />T <br />O <br />R <br />d. <br />G. Additional Descriptions for Materials Listed Above _ <br />.. <br />H. Handling Codes lot Wastes Usted <br />Above <br />15. Special Handling Instructions and Additional Information <br />16, GENERATOR'S CERTIFICATION: I hereby certify that the eonlants of this shipment are full yy and accurately <br />described and are in all respects <br />in proper condition for transport. The materials described on this <br />manifest arc not subject <br />to Iaderal hazardous waste regulations. <br />Data <br />Prinladfiyped Name <br />Signature <br />Month <br />Day <br />Year <br />} <br />'j' <br />17• Transporter 1 Acknowledgement of Receipt of Materiais <br />Date <br />R <br />A <br />Printedrtypod Nnino <br />Signature <br />,...�_ ^' <br />Month <br />Day <br />Year <br />0 <br />18. Transporter 2 Acknowledgement of Receipt of Materials <br />Date <br />TPdntedtrypedNnme <br />Signature <br />Month <br />Day <br />Year <br />E <br />R <br />19. Discrepancy Indication Space <br />F <br />A <br />C <br />20. Facility Owner or Operator: Cortification of receipt or the wasla materials cavered by this manifest, ezcopr as <br />noted in item 19. <br />L <br />' <br />Date <br />T <br />PrintedfTyped NameSignature <br />Month <br />Day <br />Year <br />Y <br />621.560ti vxv:v.iabelrnastar.corn <br />ra:cno ear <br />r�. SOYINK _ <br />Rev 495 <br />