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Special Waste Manifest <br /> Generator's Name Generator's Address Generator's Telephone No. <br /> Origin of Special Waste(Project or Spil ocation)WN r,-,wNor'.�A L�k - <br /> Transporter#1 Company Name Addr s Telephone No. j <br /> x <br /> Transporter#2 Company Name Address Telephone No. <br /> Destination Facility Name/Site Address Facility ID (PERMIT)Number Telephone No. <br /> 5t 3 <br /> Type and Proper name of special waste Containers:Number Type Total Quantity Unit Wt./Vol <br /> Irc C_ <br /> Additional Descriptions for Special Waste listed Below <br /> Special Handling Instructions <br /> GENERATOR'S CERTIFICATION:I hereby certify that the contents of this shipment are fully and accurately <br /> described above by type and proper name of the special waste,and that such waste has been managed, <br /> packaged,containerized and labeled in accordance with the requirements of 20.9.8 NMAC(Special Waste <br /> R quirements) in addition to any other applicable fe eral,state,or local regulations. <br /> ted/Typed Name ttre + Date <br /> Transporter 1 Acknowledgement of Receipt of Special Waste <br /> Printed/Typed Name Signature Date <br /> Transporter 2 Acknowledgement of Receipt of Special Waste <br /> Printed/Typed Name Signature Date <br /> Discrepancy Indication Space <br /> Facility Owner or Operator:I hereby acknowledge receipt of the special waste as indicated upon this manifest, <br /> except as noted above in the Discrepancy Indication Space. <br /> Pri e T ped Name JSignatt)' Date <br /> Generator waste form.doc <br /> Updated 7/29/19 <br />