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Please print or type.(Form designed for use on elite(12-pitcoewriter.) <br /> NON-HAZARDOUS 1 Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Waste Tracking Number <br /> 2 <br /> WASTEMANIFEST W- j-0,i�t7-tt�875i 1 900-7164419 <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> F 3 H CONSTRUCTION <br /> P.O.BOX 55245 <br /> emcFn,oN.CA R5205 <br /> Generator's Phone:1119-93,'-3 7*" <br /> 6 Transporter 1 Company Name U.S.EPA ID Number <br /> SHOPtiA.�.Ai�fJS BOLl1TIC1Nu;INC t:-A0000$46497 <br /> 7.TransporteZCpany7me U.S.EPA ISD'Number <br /> r <br /> 8 Designate aKi N me and Site Attkiress `,f 0IJA FS TFCHN CAL SL-}{_!jTI CONS LLC U. .EPA ID Number <br /> 5736 W.JEFFERSL)N ST' <br /> FHOEC• ,A°7 650,43 <br /> FstJ:d.-238-2�5 <br /> Facility's Phone: <br /> ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11 Total 12,Unit <br /> HM and Packing Group(if any)) No. Type Quantity Wt.Nol. <br /> 0 K <br /> O 1 , <br /> Z 2. <br /> w <br /> C� <br /> 3. <br /> 4. <br /> 13.SI ndling Instructions and Additional Information <br /> 10 .i f�f-E#3�+f.1282 <br /> 1 OX a 10 FOUR FT tAMPF <br /> 14 GENERATOR'S CERTIFICATION: I certify the materials described above on this manifest are not subject to federal regulations for reportingrope disposal of Hazardous Waste. <br /> Generator's/Offeror's Printed/Typed Name Signature r Month Day Year <br /> _J 15.fntbrnational Shipments <br /> ❑Import to U.S. ❑Export from- <br /> U.S. Port of entry/exit: <br /> Z Transporter signature(for exports only): Date leaving U.S.: <br /> 16.Transporter Acknowledgment of Receipt of Materials <br /> LJJTransporter 1 Printed/Typed Name Signature Month Day Year <br /> 5 i to <br /> QTraqipertlerr rinted yped/N� Signatu e Month Day Year <br /> screpancy <br /> 17a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Pejection <br /> Manifest Reference Number: <br /> 17b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U — <br /> U_ Facility's Phone: <br /> w 17c,Signature of Alternate Facility(or Generator) Month Day Year <br /> a <br /> tF <br /> 8.Designated Fa ity Owner or operator:Certification of receipt of materials covered by the manifest except as noted inItem 7a <br /> rintedlTyped me Signature Month Day Year <br /> N � <br /> 6-NHM-C-C-11 } <br /> ( 2-DESIGNATED FACILITYTO GENERATOR <br />