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NOh°rn,ti N�N N <br /> V N�� ngigned 1Or use <br /> W A2q °n ellte�12 `�A2 <br /> a TE RDO S pltchltyPewnter) ��DOUS <br /> Mq1�1 U W <br /> Nn-0,°And Mairli� SST ,.�enere,or's US EPq ID No. ASTE MAN I FE f <br /> ' k � iL#,#N� 55,.'NIL ST <br /> 4'dener MMN�I <br /> ator's Phone Manifest � <br /> '5 Trans ( i`i r�1 i. Document No. <br /> p°ter 1 OO 1 �`A z Pane i <br /> r'tpany <br /> 7.TrarlspOrter 2 C Y Name s. .i <br /> US EPA ID Number <br /> 9.Designated F A,State Transporter's ID <br /> acilitY Name and 8. <br /> {#Z�JS`ww j Site Address US EPA ID Number B.Transporter 1 Phone <br /> 4 � �1 f4����## C.State Transporter's ID <br /> r, 10. <br /> LAW US EPA ID Number D.Transporter 2 Phone <br /> *� E.State Facility'a ID i <br /> 11.WASTED CA 2. <br /> DESCRIPTION 1 <br /> {"\A IR O O V Q 9 9 a66 F. Facllity's Phone <br /> a. <br /> P� 4�tt 12. Containers 13. 14. <br /> .p lt-,d 'l y�y Total Una <br /> G 4F#b'"MF.WASTE No Type c]Total Wt.Nof <br /> E <br /> N b. <br /> E <br /> R <br /> A <br /> T °. <br /> O <br /> R <br /> d. <br /> 7' <br /> G.Additional Descriptions for Materials Listed Above H.Handling Codes for Wastes Listed Above <br /> 15.Special Handling Instructions and Additional Information <br /> _ _ - - - - - - - - - - - ► ,r <br /> The Is described on this manifest are not subject to federal and state hazardous waste regulations. a <br /> 16.GENER conditionR Ror transport. <br /> I hereby certify that the contents of this shipment are fully and accruad state <br /> described and are in all respects <br /> in proper Date <br /> Month Day Year <br /> Signature \5 `q�t f,p_ • <br /> Typed Name ;r - `- >> <br /> Printed Typ - Date <br /> Month Day Year <br /> 17.Transporter 1 Acknowledgement of Reciept of Materials Signature <br /> APrinted Typed Name ' Date <br /> N Month Day Year <br /> S •p 18.Transporter 2 Acknowledgement of Reciept of Materials Signature <br /> T Printed Typed Name J <br /> �\ YF <br /> E <br /> 19,Discrepancy Indication Space ' <br /> this manifest,except as noted in item 19. Date . <br /> 20,Facility owner or Operator,GeNfication of receipt of the waste materials covered by Month Day Year <br /> Signature <br /> r Printed Typed Name <br /> Year <br />