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f'Isctffe not or t <br /> Form tleslgned far use on NONHAZARDOUS WASTE <br /> ellle(12 pitch)typewriter) MANIFEST <br /> WASTE MAN HAZARDO <br /> EST 1'Generator <br /> 3 's US EPA ID No. <br /> -�ti�(]�r;ttol's Name and Molin Manifest z P. a e 1 <br /> 10S 9 Address Document No. <br /> �} l�,rtj of <br /> 4.Generator's Phone( CA <br /> 5.Transporter l <br /> Company Name <br /> 6' US EPA ID Number <br /> 7.Transporter 2 Com <br /> A r A.State Transporter's ID <br /> pany Name B.Transporter 1 Phone - <br /> 8. US EPA ID Number <br /> C.State Transporter's ID <br /> S.Designated Facility Name and Site Address D.Transporter 2 Phone <br /> 10' US EPA ID Number E.State Facility's ID <br /> �� <br /> l R0 HuL%�IF <br /> umtitj('JT'Y F. Facility's Phone <br /> 11.WASTE DESCRIPTION <br /> 12. Containers 13. 14. <br /> Total Unit <br /> a No Type Quantity Wt./Vol <br /> G 14014 HAZARDOUS UQUID(SUMP t ASTr) <br /> E <br /> N b. <br /> E <br /> R <br /> A <br /> T <br /> O <br /> R <br /> d. <br /> W <br /> F— <br /> U) <br /> G.Additional Descriptions for Materials Listed Above H.Handling Codes for Wastes Listed Above <br /> O <br /> Q <br /> Q 15.Special Handling Instructions and Additional Information <br /> tf,�1�.ij3�'f `s�`TF'r:t!�t�Al. *F�:Ktt.�=E).k- li' 4 �.t ,� r*t`� , 1�r�+,�,r,.�•:�A�r <br /> 41 P".at f as <br /> Z <br /> O <br /> Z <br /> 16.GENERATOR'S CERTIFICATION:I hereby certify that the contents of this shipment are fully and accruately 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 Month Day Year <br />" T 17.Transporter 1 Acknowledgement of Reciept of Materials Date <br /> R <br /> A Printed Typed Name Signature Month Day Year <br /> N <br /> S <br /> w P <br /> RO 18.Transporter 2 Acknowledgement of Reciept 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,Cert'itication of receipt of the waste materials covered by this manifest,except as noted in item 19. <br /> L <br /> Date <br /> r Printed Typed Name Signature Month Day Year <br /> Y <br />