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NONHAZARDOUS WASTE MANIFEST <br />Ptnasn mint nr tvnn (Form desionad for use on elite (12 pitchy 1Vnerrr11e0 <br />NON -HAZARDOUS <br />WASTE MANIFEST <br />3. Generator's Name and Wiling Address <br />ikol IIi{"s'$tnt.rC'S1 <br />42Cf Al Ytl'J.-.1shirfat=iia .rani?. <br />A. Generator's Phone ( - <br />t. Generator`s US EPA ID Na. <br />(� i i(Y 11 P -14 %i F <br />5. Transporter 1 G'dmpany Namo <br />:3Jvansni r'1 t"; .>=tri6i;i74 T'a pct ,tjt tae:. (9VI <br />7. Transporter 2 Company Hama <br />g. Designated Facility Name antl 5ile Address <br />If 44;AUA V'ti#.Y{,`.v.ea <br />'•lovid6(gr E CAW'itaiii <br />t t. WA5TE DESCRIPTION <br />C <br />N <br />E <br />R <br />A <br />T <br />0 <br />R d. <br />T <br />R <br />N <br />S <br />P <br />p <br />R <br />T <br />R <br />F <br />A <br />C <br />I <br />L <br />I <br />T <br />Y <br />ffffmfMff <br />G, Additional Dascdptidns for kiaterlals listed Above <br />1v. Special Handling Instruetlons and Addlilonai intdirptll�hl:� <br />,t <br />8. US EPA ID Numher, <br />B. US EPA ID Number <br />fdanttost <br />74. <br />total <br />2. Page 1 <br />pecument No, <br />t <br />) 7 (¢ ' <br />j 07 <br />1of <br />A. State Transporters ID <br />B.Transporter1 Phone E�Pj�f-5 4 <br />C. State Transporters ID <br />D.Transponer2 Phone <br />f0. US EPA ID Namber ( E. Sfafa Facility's Ip <br />C AD W03 VU2 III <br />tis HUaa�i ti=��yscc��xtt�: <br />F. Farility's Phone <br />Cofntainers <br />No. I Typa <br />13. <br />74. <br />total <br />Un(I <br />Quantity <br />Wt.Not. <br />H. Handling Codas for Wastes Listed Ahove <br />is. GENERATOR'S CERTIFiCATIDN: I <br />Hereby certify that the contents of This shipment ere <br />IuIN <br />antl accurately described and are fn alt respects <br />in proper wnditldn for transport. The <br />matena!s described on this manifest ate not subJect <br />to <br />ederai hazardous tvaste regulations. <br />Date <br />Printed�Typed Name _, Signature t Manfh Day Year <br />17, Transporter 1 Acknowledgement of Receipt of Materials Date <br />Ptinled/Typed Name Signature Month Day Year <br />18. Transperter2 Acknovdedgernentof Recelpl of Materials Date <br />PrintedrTypnd Name Signature Month Day Year <br />19. Discrepancy Indication <br />Space <br />20. Fadiity Ownae or Operator Cdnilication al receipt of the waste matoriats covered by tnls manliest, escopl as noted in Item 19. <br />PrintadlTyped Name <br />CF1d <br />r�� 2pp2 LAHELMASTERp (8pp) 821-58D8 WWWJAb6IrilAStt3r.COnt <br />Signature <br />Date <br />Month Day Year <br />®NN�.t` ESA 1^Et6E+vs0vulP <br />SOYINH <br />