Fillable Form desi: NON-HAZARDOUS WASTE MANIFEST

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Form desi: NON-HAZARDOUS WASTE MANIFEST

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NON-HAZARDOUS WASTE MANIFEST
3. Generator’s Name and Mailing Address
4. Generator's Phone
5. Transporter 1 Company Name 6. US EPA ID Number
7. Transporter 2 Company Name 8. US EPA ID Number
9. Designated Facility Name and Site Address 10. US EPA ID Number
11. WASTE DESCRIPTION
a.
b.
c.
d.
G. Additional Descriptions for Materials Listed Above H. Handling Codes for Wastes Listed Above
15. Special Handling Instructions and Additional Information
16. GENERATOR’S CERTIFICATION:
Printed/Typed Name Signature
17. Transporter 1 Acknowledgement of Receipt of Materials
Printed/Typed Name Signature
18. Transporter 2 Acknowledgement of Receipt of Materials
Printed/Typed Name Signature
19. Discrepancy Indication Space
20. Facility Owner or Operator; Certification of receipt of the waste materials covered by this manifest, except as noted in item 19.
Printed/Typed Name Signature
A. State Transporter's ID
B. Transporter 1 Phone
C. State Transporter’s ID
D. Transporter 2 Phone
E. State Facility’s ID
F. Facility’s Phone
12. Containers 13. 14.
Total Unit
No. Type Quantity Wt./Vol.
Manifest
Document No.
2. Page
1. Generator’s US EPA ID No.
Date
Month Day Year
Date
Month Day Year
Date
Month Day Year
Date
Month Day Year
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Please print or type
(
Form desi
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ned for use on elite
(
12 pitch
)
typewriter
)
NON-HAZARDOUS
WASTE MANIFEST
NO
N-HAZARD
OUS
WA
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Copyright © 2006, ShipMate, Inc.®, All Rights Reserved
) (310) 370-3600 www.shipmate.com
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Form desi: NON-HAZARDOUS WASTE MANIFEST

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Completed 11 January 2021

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