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W <br />0 <br />0 <br />cc <br />Oct <br />N <br />a <br />z <br />z <br />NONHAZARDOUS WASTE MANIFEST <br />Please print or type (Form deigned Ior Otto on c io (1z path} typewntOr, <br />CF14 G 2002 LAt36LMn5TERQ (804) 621.5808 wwlv.labelmaster, <br />NON -HAZARDOUS <br />1 Generator's US EPA ID No. <br />Manifest <br />z Pagel <br />-r. WASTE MANIFEST <br />�.' ... l�.s��4W%'� <br />oacumanlNa. �,{, <br />of d <br />3. Generators Name and idaitiag Address <br />I. <br />f'i'tll vi r'd�Cr �t1JF[ <br />P <br />1# ��. �;. . 4y 1s r .� �. ..s <br />Phane f- s 1(> 1% X 2 t <br />4. Generators { <br />5. Transporter 1 Company Name 6. <br />US EPA ID <br />Number <br />A. State Transporter's ID <br />I <br />S. Transporter I Phone ? (3 <br />Y' T'iF4 • :I i <br />. <br />7 Transporter 2 Company Name 9. <br />US EPA ID <br />Number <br />C. State Transporters ID <br />D. Transporter 2 Phone <br />_ <br />9. Designated Facility Name and Site Address 10. <br />US EPA ID <br />Number <br />E. State Facility's ID <br />�'Ofwjlfd Law tit <br />,r1.xt; <br />F. Facility's Phone <br />11. WASTE DESCRIPTION <br />Containers <br />13. <br />14. <br />33, <br />Ta <br />Unit <br />ti <br />No. Typo <br />Quantity <br />ty <br />WtNol. <br />th'ia.��� �*.,.1 �.r4'i @'I)i tiFr:�f'E•s hit9l�S� <br />�� <br />S�.f�.Fii'lt"'1 <br />, a. <br />trtr <br />f� <br />b. <br />E <br />N <br />E <br />R <br />C. <br />A <br />T <br />O <br />R <br />d <br />G. Additional Descriptions for fdatenmis Listed Above <br />H. Handling Codes for Wastes Listed <br />Above <br />Ptn'zit lrilftci:vic 7?4 1 <br />(jA <br />t <br />'s <br />�1 <br />Syr <br />15. Special Handling Instmclions and Additional Information <br />16. GENERATOR'S CERTIFICATION I hereby certify that ilia contents of this shipment aro full yy and accurately descabed <br />and are in all respects <br />in proper condition for transport. The materials dascribecf on this manifest are net subject to federal <br />hazardous waste regulations. <br />Date <br />Printea:Typed Name t <br />Signature <br />Motah Oily Year <br />T <br />17- Tramportor 1 Acknov.1adgemenl of Receipt of Fdaterials <br />Date <br />R <br />A <br />PrinImIlTyped Name <br />Signature . <br />Rlonth Day Year <br />0 <br />16. Transporter 2 Acknowledgement of Roc oipt of Materints <br />Date <br />R <br />T <br />Pnnled:'ryped Name <br />Signature <br />Manth Day Year <br />E <br />R <br />ff <br />19 Discrepancy Indication Space <br />F <br />A <br />C <br />120. <br />Facility Owner or Operator: Cor ificalion of receipt of ilio waste materials covered by this manifest, <br />except as noted in <br />item 19. <br />D <br />Date <br />T <br />PdntedlfypedName <br />Signature <br />Month Day Year <br />Y <br />tom <br />tS01!�1NN <br />