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NON-HAZARDOUS 1. Geneators US EPA ID No. Manifest Doc. No. 2. Page 1 <br />WASTE MANIFEST pf <br />3. Generators Name and Mailing Addr <br />~; <br />~ <br />a <br />~ ~ r <br />t~1 ~ <br />j y <br />a. Generators Phone ( ) <br /> 5. Transporter 1 Company Name 6. US EPA ID Number A. Trensportels Phone <br /> 7. Transposer 2 Company Name e. US EPA ID Number B. Trensporter's Phone <br /> 9. Designated Facility Name and Site Address 10. US EPA ID Number C. Facility's Phone <br /> <br /> 11. Waste Shipping Name and Description 12. Containers 13. <br />Total 1a. <br />Una <br /> No. Type Ouantiry WWoI <br /> a. <br /> <br />G b. <br />E <br />N <br />E <br />R <br />A c. <br />T <br />O <br />R <br /> d. <br /> D. Additional Descriptions for Matedals Listetl Above ~ E, HarMling Codes for Wastes listed Afwve <br /> 15. Special Hantlling Instructions and Additional Information <br /> 16. GENERATOR'S CERTIFICATION: I eertly the materials descdbed above on Uk manlfesl ere not svgect to federal regulatlons for reporting Proper disp0.sal of Harardous Waste. <br /> Printed?yped Name Signature Moran Day rear <br /> SD n <br />R 17. Transporter 1 Acknowletlgement of Receipt of Matedals <br /> <br />A P <br />9'nted/Typed Name Signature r <br />"s . <br />nQ S/ eL ''0 <br />P <br />O 18. Trenspoder 2 AcknovAedgement of Receipt of Matedals <br />R <br />E Pdnted/Typetl Name Signature Month Day veer <br /> <br />R <br /> 19. Discrepancy Intlication Space <br />F <br />A <br />C <br />I <br />~ 20. Facility Owner or Operator: Certification of receipt of waste materials covered by this man'rfest cept as noted in Item 19. <br />I <br />T ~ t <br />Y PdntedRyped Name Signature _ <br />f7e rear <br /> \ - - <br />t vw <br /> ORIGINAL -RETURN TO GENERATOR <br />