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� 1 <br /> I w <br /> r�NON_ (Formtlesig^e NO <br /> " HAZ d for use N� A D <br /> Aqp °^elite(12 N ` '1 <br /> WASTE M OuS Pitch) Zq 0 1A, <br /> s Generator'.Name andAN 9FEST 1 Ce^eraeo St US EPA D �� V <br /> Address AIDN .4,s MANIFEST <br /> 4.Generatdr' <br /> 5.Trans <br /> s Phone <br /> Porlej Mamfesl <br /> 1 Cor^Pany Namej Document No. <br /> 2 Page 1 <br /> 7.Transporter 2 Company Name oI <br /> s. <br /> 9.Designated F US EPA ID Number <br /> acili <br /> ry Name and Site Address B. A.Stale Transporter,to <br /> US EPA ID Number 6.Transporter 1 Phone <br /> 10 C.State Transporters ID <br /> US EPA ID Number D.Transporter 2 Phone <br /> 11.WASTE DESCRIPTION E.State Facility's ID <br /> a. F.Facility's Phone <br /> 12 Containers <br /> 3. 4. <br /> Total <br /> mt <br /> G b. NO Type Quantity WI Nol <br /> E <br /> N <br /> E <br /> R c. <br /> A <br /> T <br /> 0 <br /> R d. <br /> N 1 <br /> Q <br /> �j G.Additional Descriptions for Materials Listetl Above ' <br /> N H.Handling Codes for Wastes Listed Above <br /> u � <br /> 0 <br /> z <br /> Q <br /> Q15 Special Handling Instructions and Additional Information , <br /> _ <br /> z i <br /> 0 <br /> z <br /> 16.GENERATOR'S CERTIFICATION:I hereby certify that the contents of this shipment are fully and accurately described and are in all respects <br /> in proper condition for transport.The materials described on this manifest are not subject to federal and state hazardous waste regulations. <br /> Date ' <br /> Printed/Typed Name Signature <br /> Month Day Year <br /> T 17.Transporter 1 Acknowledgement of Receipt of Materials , <br /> R Date <br /> rq Printed/Typed Name Signature Month Day Year { <br /> S CI <br /> P <br /> p 18.Transporter 2 Acknowledgement of Receipt of Materials Date <br /> T Printed/Typed Name Signature Month Day Year <br /> E <br /> R <br /> 19.Discrepancy Indication Space <br /> F <br /> A <br /> C <br /> 1 20 Facility Owner or Operator,Certification of receipt of the waste materials covered by this manifest.except as noted in item 19. <br /> L <br /> Dale <br /> T PrintWyped Name Signature Month Day Year <br /> Y <br />