SAMPLE MANIFEST FORM

							                                                                  SAMPLE MANIFEST FORM
                                                                         COUNTY OF HENRICO
                                                                        Department of Public Utilities

                                                            TRUCK HAULED WASTE MANIFEST
                                                                                  (Revised 6/98)

Date of Pickup                                              Origin of Waste                                           Telephone         Est. Volume
                                                      Complete Name and Address*                                       Number            ( gallons)
June 8, 2002          Mr. James A. Taylor, 1234 Colgate Lane, Richmond, VA, 23231                                      795-9333             2,000
June 9, 2002          B&B Market, 2345 Jamestown Street, Hanover Courthouse, VA 23116                                  550-3109             1,500




                                                                                                                            Total           3,500
    Vehicle License Number_____________________
                                                                                        *County of Origin: Henrico and Hanover
    Name of Company        Mister Potty, Inc.                                                                  (MUST INCLUDE)
                                                                                        Property owner________Yes________ Tenant_________________
    Mailing Address P.O. Box 9876
                                                                                                              FOR COUNTY USE ONLY
    Richmond, VA 23456
                                                                                         Ticket Number                ___________________________

                                                                                         Account Number               ___________________________
    Telephone Number 804.987.3456
                                                                                         Sample I.D. Number           ___________________________
    I certify that no other unreported wastes are being discharged and that the
    wastes reported herein contain no industrial or hazardous material.                  THW Permit Number            ___________________________

    ____________________________________June 10, 2002________                            Comments:
    Authorized Representative                        Discharge Date