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t'lees0 print or t <br /> Ype NON_HAZAR� , <br /> (Form desi77­- gned for <br /> NON_HAZA O'IS"onelite(12Pitch)typew ter) OUS WASTE MANIFEST <br /> WASTE MAN-HAZARDOUS 1.Generator's US EPA ID No. <br /> 3 Generator's and Mailing Address Manifest 2.Page 1 <br /> �ft T Li <br /> t Add Document No. ofRI- NE !',I- RAIL-t:f et�thll S�t��3 <br /> 4.Generato s p"Phone S.Trans ) �5 s CA <br /> Porter 1 Company Name <br /> 6. US EPA ID Number A.Slate Transporter's ID <br /> 7 Transporter 2 C <br /> ompany Name B.Transporter 1 Phone <br /> 8. US EPA ID Number C.State Transporter's ID <br /> 9.Designated Facility Name and Site Address <br /> D.Transporter 2 Phone <br /> �y P ytJ at�_`• E.1,�y 10. US EPA ID Number E.State Facility's ID <br /> 5P I NIT REiCi i 11-O .LA HE <br /> "IN CITY F. Facility's Phone <br /> 11-WASTE DESCRIPTION <br /> 12. Containers 13. 14. <br /> Total Unit <br /> a. <br /> No Type Quantity Wt.Nol <br /> liVR HA>ARDOtfi; tJQJitt)(SUMP WA5Ttr3 <br /> G <br /> E <br /> N b. <br /> E <br /> R <br /> A <br /> T <br /> O <br /> R <br /> d. <br /> G.Additional Descriptions for Materials Listed Above <br /> H.Handling Codes for Wastes Listed Above <br /> I <br /> I <br /> I <br /> 15.Special Handling Instructions and Additional Information <br /> I <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 /> P Date <br /> D 18.Transporter 2 Acknowledgement of Reciept of Materials <br /> R <br /> T Printed Typed Name Signature Month Day Year <br /> c <br /> 3 <br /> 19.Discrepancy Indication Space <br /> 20.Facility Owner or Operator,Certification of receipt of the waste materials covered by this manifest,except as noted in item 19. <br /> Date <br /> Printed Typed Name Signature Month Day Year <br />