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3 <br /> Published by J.J.KELLER&ASSOCIATES,INC.,Neenah,WI•USA•(800)327-6868•www.Ekeller.com•Printed in the United States <br /> NON-HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Waste Tracking Number <br /> Ir WASTE MANIFEST NOT APPUCA BLE <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> Generator's Phone: <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> NOT APPLICABLE <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> WrAMMASLE <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> CCILyNt MAY ROAD NOfAPP f + B LE <br /> HAY ROAD-VACAVILLE,CA 95M <br /> Facil' s Phone: MM 67"718 <br /> 10.Containers 11.Total 12.Unit <br /> 9.Waste Shipping Name and Description <br /> No. Type Quantity Wt.Nol. <br /> cc <br /> 1. <br /> O <br /> a <br /> w <br /> z 2 <br /> w <br /> O <br /> 3. <br /> 4. <br /> 13. Special Handling Instructions and Additional Information <br /> 14.GENERATOR'S CERTIFICATION:I certify the materials described above on this manifest are not subject to federal regulations for reporting proper disposal of Hazardous Waste. <br /> Generator's/Offeroes Printed/ryped Name Signature Month Day Year <br /> 15.International Shipments <br /> z ❑Import to U.S. ❑Export from U.S. Port of entry/exit: <br /> Transporter Signature for exports only): Date leaving U.S.: <br /> cc 16.Transporter Acknowledgment of Receipt of Materials <br /> Lu <br /> ¢ Transporter 1 Printedrryped Name Signature Month Day Year <br /> O <br /> CL <br /> y <br /> z Transporter 2 Printed/Typed Name Signature Month Day Year <br /> cc <br /> F <br /> 17.Discrepancy <br /> 17a.Discrepancy Indication Space <br /> ❑Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> >- 17b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> ` U <br /> rat Facility's Phone: <br /> LOU 17c.Signature of Alternate Facility(or Generator) Month Day Year <br /> a <br /> z <br /> 18.Designated Facility Owner or Operator.Certification of receipt of materials covered by the manifest except as noted in Item 17a <br /> Printed/ryped Name Signature Month Day Year <br />