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P NON -HAZARDOUS WASTE MANIFEST <br />Please nrinf nr tuna rFnrm ria l4 rl Inr use nn alit, n9 .4ieh% Wim- ;ka % <br />v. 1uesignauso racmry rvame ane tae Aaaress 1u. u5 LFA IU Number <br />i lqs-' , I�Cf WY, - <br />v) 5-- C 1 a P-oa , P-0 { rt OZ L' 15-11 ! I <br />!f�,KD \1 ( sTR-t r h <br />'11. WASTE DESCRIPTION <br />NON -HAZARDOUS.._ <br />WASTE MANIFEST <br />1. Generator's US EPA ID No. <br />Manifest 2. Page 1 <br />°°°ame°'2 (- �`r�%1 ; of f <br />Dale <br />3. Generator's Name and Melling Address_ P,(� 0 5 5 * <br />?rte G t.l `l <br />CA <br />4. Generator's Phone ( ) S�QC k�i0 I� l A <br />CAvf'�1a^��� <br />G <br />b. <br />5. <br />5. Traansporter 1 Company Name n 6. US EPA ID Number <br />c T� �� N Ci — K <br />A. State Transporter's ID <br />B. Transporter 1 Phone <br />P : �,�� F <br />r <br />7. Transporter 2 Company Name B. US EPA ID Number <br />C. State Transporter's ID <br />D. Transporter 2 Phone <br />v. 1uesignauso racmry rvame ane tae Aaaress 1u. u5 LFA IU Number <br />i lqs-' , I�Cf WY, - <br />v) 5-- C 1 a P-oa , P-0 { rt OZ L' 15-11 ! I <br />!f�,KD \1 ( sTR-t r h <br />'11. WASTE DESCRIPTION <br />E. State Facility's ID <br />F. Facility's Phone <br />12. Containers 13. <br />Total <br />No. I Type Quantity <br />H. Handling Codes for Wastes Listed Above <br />16. GENERATOR'S CERTIFICATION: I hereby certify that the contents of this shipment are fully and accurately described and are in all respects <br />in proper condition for transport. The materials described on this manifest are not subject to federal hazardous waste regulations. <br />14. <br />Unit <br />W I.Noq. <br />Date <br />Printecirryped Name Signature Month Day Year <br />T 17. Transporter 1 Acknowledgement of Receipt of Materials <br />R <br />a. <br />Dale <br />11G <br />ho- V t,. ZAQ cOJM o i T c Q; NJ W e U, Ili R't 1711— <br />A Prid1Typed N9me� <br />N , ' <br />G <br />b. <br />Month <br />E <br />Y e r <br />P : �,�� F <br />r <br />N <br />. <br />(� <br />E <br />1 <br />R 18. Transporter 2 Acknowledgement of Receipt of Materials <br />R <br />cr <br />_A <br />T Printed/Typed Name <br />T <br />Month <br />O <br />Year <br />W <br />R <br />d, <br />H <br />N <br />F 19. Discrepancy Indication Space <br />G. Additional Descriptions for Materials Listed Above <br />D <br />0 %) - id <br />O <br />p <br />�-�o=- <br />C <br />Q <br />Q15. <br />Special Handling Instructions and Additional Information <br />y h� ` <br />Z <br />O <br />I 1\U� f <br />Z <br />Date <br />E. State Facility's ID <br />F. Facility's Phone <br />12. Containers 13. <br />Total <br />No. I Type Quantity <br />H. Handling Codes for Wastes Listed Above <br />16. GENERATOR'S CERTIFICATION: I hereby certify that the contents of this shipment are fully and accurately described and are in all respects <br />in proper condition for transport. The materials described on this manifest are not subject to federal hazardous waste regulations. <br />14. <br />Unit <br />W I.Noq. <br />Date <br />Printecirryped Name Signature Month Day Year <br />T 17. Transporter 1 Acknowledgement of Receipt of Materials <br />R <br />Dale <br />A Prid1Typed N9me� <br />N , ' <br />Sig Aturg' <br />r / <br />/ <br />Month <br />Day <br />Y e r <br />P : �,�� F <br />r <br />. <br />(� <br />1 <br />R 18. Transporter 2 Acknowledgement of Receipt of Materials <br />tom' ` <br />�� <br />Date <br />T Printed/Typed Name <br />Signature <br />Month <br />Day <br />Year <br />E <br />R <br />F 19. Discrepancy Indication Space <br />A <br />C <br />1 20. Facility Owner or Operator; Certification of receipt of the waste materials covered by this manifest, except as noted in item 19. <br />L <br />y h� ` <br />I 1\U� f <br />Date <br />T Printed/Typed Name <br />Y �� t <br />Signature <br />Mgn1h <br />Day <br />Year <br />;10. c"tC Li, , _ <br />(/O <br />14- <br />;1 <br />F-14 © 2002 LABELT" IASfER ® (800) 621.5808 www.labelmaster.com <br />u�rro nn <br />Rev. .?W <br />[NK _ <br />