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■ at vi ■ v il <br /> NON-HAZARDOUS WASTE MANIFEST FEB 17 2016 <br /> Please print or type _ (Form designed for use on elite(12 pitch)typewriter) <br /> NON-HAZARDOUS GenemofsU9EPA IDNo. Manifest mverdNo of <br /> WASTE MANIFEST HEALTH DEPAR MrENT d <br /> 3.Generamfs Name and Mailing Address iL, Aa CHUQCH <br /> )oy 4J_ F*_vBt.L'7 I'L 11CaE <br /> 4.Generale,S Phone( ) TR t3Ck CA <br /> 5.Transporter 1 Company Name b. US EPA ID Number A.Slate Transporters ID <br /> IN S.T-y-v\-T- I N C I E.Transporter 1 Phone <br /> 7.Transporter 2 Company Name g. US EPA ID Number C.Stale Trensportar's ID <br /> D.Transporter 2 Phone <br /> 9.Designated Faddy Name and Site Address ID. US EPA ID Number E.State Facility's ID <br /> "RTMb <br /> F.Facility's Phone <br /> 14 <br /> 11,WASTE DESCRIPTION 12. <br /> Containers <br /> Unit <br /> No. Type Quantity WINol, <br /> a. Lt <br /> G b <br /> E <br /> N <br /> E <br /> R <br /> A <br /> T <br /> a <br /> 1 <br /> R d <br /> t G.Additional Descriptions for Materials Usted Aticve H.Handling Codes Por Wastes Wed Above <br /> t <br /> C75,Special HandAng Instructions and AdtlNonal Inbrination <br /> i <br /> AFAWAV <br /> i&GENEEATDR"5 CERTIFiCA'tiON:I heBGy cc <br /> hify that the contents of IMS shipment are fu and accurately lawdood and are In ail respects <br /> in proper wntldlOn for panspoh.Tha materials tlascribed on This mangestare not wbfecl to federal hazardous waste regNaliana. <br /> Dam <br /> Signature Monis Day Year <br /> PrmtedlTYped Name <br /> T 17.Transporter 1 Acknowledgement of Receipt of Materials Date <br /> 6amegnatore -� Q� ��r <br /> S <br /> P70nwdTypodN[( j • t� <br /> IS.T,,t der 2 AMmowt dgemela of Receipt of Materials Data <br /> g Month Day Year <br /> T PrmlerNyped Name SI nature <br /> E <br /> R <br /> 19.Discrepancy Indication Space <br /> F <br /> A <br /> C <br /> ) 2o.Facility Owner or Operator,Certification of receipt of the waste mseadals covered by INS elf ilest accept as noted in item 19. <br /> L Dale <br /> Signature Day Year <br /> 'f' PrintedfTyped Name - t-. I Mort, 1/ <br /> Y' Miff MAE_ ti 5t{tTEFi � Y • 4? <br /> Rev.395 <br /> F-14 m20g2 LA3ELA'IASTEam IBM)621-5Mwww.iabalmasiar.com. <br />