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FW- <br />O <br />0 <br />cc <br />a <br />N <br />a <br />x <br />z <br />z <br />N0N-HAZARDOUS WASTE MANIFEST <br />Please print or type SFarm designed far use on elite (12 pitch) typowriler) <br />` <br />GF14 <br />NOWHAZARDOUS <br />1 GenatatorsUSEPAiDNo. <br />Manifest <br />2, <br />Page <br />: <br />WASTE MANIFEST <br />i,�-.tFf{i- <br />DocumantNo. ,,}fxj'?; <br />of <br />3. Generators Namo and Naffing Address <br />fifl?( f3{ K7{ic(ifl1:'4 <br />:l Generator's Phone; <br />5.7ransparier 1 Company Nnme <br />6. US EPA ID Number <br />A. State Transporters IQ <br />At d5t ;t3if � ti5fi'rst':ni {3:1i'r?;�tt:rY{ �Yt:: t Tl� <br />�_ i��f�(�{ij{} �i`yr�rt <br />#y <br />{ I,1 # u '7a, <br />B. Transporter I Phone <br />Kl' <br />7. Transporter 2 Company Namo <br />8. US EPA 10 Number <br />C. Stain Ttansponers ID <br />D. Transporter 2 Phone <br />9. Designated Facilily Name and Site Address <br />10. US EPA ID Number <br />E. State Facility's ID <br />r�2e1siTllC:iriei 1.:tf1t!41t1r'33{ PfZ.it`:fit')3{i tlkt': (�k�'�� <br />F. Facility's Phone <br />F ste f a1, f"�.Tt:;'.;h <br />11. WASTE pESCRIPTION <br />Confuiners <br />13. <br />Total <br />td. <br />Unit <br />No- Typo <br />Ouamity <br />Wt�Nol. <br />G <br />b. <br />E <br />N <br />E <br />R <br />c. <br />A <br />T <br />Q <br />R <br />d <br />G Additional Descriptions for Materials Listed Above <br />H. Handling Codes for Wastes Listed <br />Above <br />�='tilt.'_w!;._........-...�_:....-i <br />15. Special Handling Instructions and Additional intormallon <br />16, GENERATOR'S CERTIFICATION: I hereby certify that the contents of this shipment are full yy and accurately described and are fn all respects <br />In proper condition for transport. Tire mnlenais described <br />on this manifest are not subject to Ioderal hazatdous waste regulations. <br />Onto <br />3 <br />Pnntodrfyped Name <br />Signature <br />Month <br />Day Year <br />T <br />17. Transporter 1 Acknowledgement of Receipt of Materials <br />Data <br />R <br />PrintedrTyped Name <br />Signafura <br />Month <br />Day Year <br />N <br />P <br />0 <br />18. Transposer 2 Acknowledgemont of Receipt of Materials <br />Date <br />R <br />T <br />Prinled:Typed Name <br />5tynature <br />Month <br />Day Year <br />E <br />R <br />19. Discrepancy Indication Space <br />F <br />A <br />C <br />20. Facility Owner or Operator: Conification of roceipt of the <br />waste matodais covered by this manifest, except as noted in item 19 <br />L <br />( <br />Date <br />T <br />Printed/Typed Name <br />Signature <br />Month <br />Day Year <br />Y <br />02002 LABEiMASTERm (800)621.5808 wvnv.labeimastEr.com <br />s.:i�IDv:,(`r..ly✓aYfn �`6w.tq� <br />