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1. Generator's US EPA ID No. Manifest Doc. No. 2. Page 1 -~' <br />of <br /> .~.5 ~s <br /> 6. US EPA ID Number A. Transporters Phone <br /> 6. US EPA ID Number B. Transporters Phone <br /> 10. US EPA ID Number C. Facilitys Phone <br /> 12. Containers <br /> <br />No. Type 13. <br />Total <br />Quantity 14. <br />Unit <br />WWoI <br /> 17y«~~ <br /> <br /> <br /> <br /> D. Adtliaonal Descdptions for Materals Listed Above E. Handling Codes for Wastes listed Above <br /> 16. Special Handling Instructions and Additional Information <br />16. GENERATOR'S CERTIFICATON: I cerGly Ne materials describe0 above on Mis mangest are not svbied to federal regulations for reporting proper disposal of Hazardous Waste. <br />Pdnted/Typetl Name Signature Afonm oaY Year <br />7 17. Transporter 1 Acknowletlgement of Receipi of Materials <br />R <br />S <br />Pnnted?ypetl Nam ` ,y <br />Signature <br />/~' _ O <br />araam oay <br />rear <br />H 1B. Tmnsponer 2 Acknowletlgement of Receipt of Materials <br />E <br />R Printetl/Typed Name Signature Month Day Year <br />19. Discrepancy Indication Space <br />Facility Owner or Operator: Cenification of receipt of waste materials covered by this manites; except as notetl in Item 19. <br />Pdnted/T a <br />i <br /> <br />ORIGINAL -RETURN TO GENERATOR <br />