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W <br />N <br />'Q <br />0 <br />Q <br />N <br />d <br />r <br />z <br />0 <br />z <br />NON -HAZARDOUS WASTE MANIFEST <br />Please print or type (Form designed for use on aNe (12 pitch) typewriter) <br />NONHAZARDOUS I. GoneratoesUS EPA ID No. <br />WASTE MANIFEST 11'A I�t�Y14I ' I <br />3. Generator's dame and Mailing Address <br />PG11 t5{ St* fA't`{9r'c <br />';��i'I tla?C:10+'4rts %vex, <br />>f- AerL Witt, A95�.1 '} <br />a, Generator's Phone <br />5. Transporter 1 Company Name <br />ritfiii?ttC i (;;ir_dYts='iy1 itxieFm t'ist }rwe" <br />7. Transponar 2 Company llama <br />g. 0asigna!ad Facility Namo antl S!te Address <br />{��i?J�r7dtt {�tisd�:�J �`9:3g1� �r1 E Mari `~i�:sss{•, <br />r-bArnw zr) Landfill <br />11 WASTE DESCRlPTICPl <br />E <br />N <br />R �. <br />A <br />T <br />0 <br />R d. <br />t <br />G. Additions! Dascrlptlnns tar Materials l.lstod Above <br />s. US EPA ID Number <br />8. US EPA ID Number <br />to. US EPA (D Number <br />J4¢n!feat 12, Page 1 <br />Document No, 1 10096 <br />Of <br />A. Stats Transporter's Ip <br />8, Transporter i Phone <br />C. State Transponer's ID <br />D. Transporter 2 Phone <br />E. State Faculty`s ID <br />CALMOVIO-?J is <br />F. Fecflirrs Phone <br />Ccntalners <br />No. I Type <br />t5. Spacial Handling Instructipnsantl Additions! Inlola���t� �.�Ii1Pb£t�E �F.►���t nL�ill.tlEblt"1iT (�: CT�ti#;f';3E�� <br />i <br />13. <br />Total <br />t�uantfty <br />H. Handl!ng Codes Ior Wastes t,lsted Above <br />16. GENERATOR'S CERTIFICATION: I hsrebyy certify that the contams of Ihls shipment era tul�y and accurately dascr!bed and ars (n a!1 respects <br />in proper cond!Ilon for transport. The materJals descnbad on Ihts mantfast are rpt subject to federal hazardous tvasto regutat!ons. <br />1 a. <br />Unft <br />Wt.Nol, <br />Signature Month Day Year <br />�� Printad:iyped Name <br />T 17, Transporter i Acknowledgement of Receipt of Materials Date <br />R <br />A PriniedlTyped Name Signature ` Month Day Year <br />0 18. Transporter 2 Acknowledgement of Receipt of Materials Date <br />R <br />T PrimedfTyped Name Signature Month Day Year <br />R _ -J <br />F <br />C <br />I <br />L <br />A <br />LY <br />19. Discrepancy tndicatlen Space <br />20 Facility Owmer or Operator CanificaUon of receipt of the v+aste matetlals cavar¢d by this manliest, axrapt ¢s nolad fn item t9. <br />PrintarLTypad Name <br />CF14 02002 LAAELMASTER® (800) 621-5808 www.lttbalmaster.com <br />Signature <br />Date <br />1Aonth Day Year <br />arra c.ncevnroeur+ ��.,, <br />�s�.anwx .SINN <br />