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Published by J.J.KELLER&ASSOCIATES,INC.,Neenah,WI•USA•(800)327-6868•www.jjkeller.com•Printed in the United States NON-HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Waste Tracking Number WASTE MANIFEST APPLICASLE 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) Generator's Phone: 6.Transporter 1 Company Name U.S.EPA ID Number #APPUCA LIE 7.Transporter 2 Company Name U.S.EPA ID Number ICAlk-_ 8.Designated Facility Name and Site Address U.S.EPA ID Number {`OU'M HAY ftOAD NOT :-ICABLE 14-126 HAY ROAD.VACAVIL E,CA 95M7 Facil' 's Phone: -(MM-4718 9.Waste Shipping Name and Description 10.Containers 11.Total 12.Unit No. Type Quantity Wt.Nol. Ir 1. O H a oC Lu Z 2. w cs 3. 4. 13. Special Handling Instructions and Additional Information 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. Generator's/Offerors Printed/Typed Name Signature Month Day Year j 15.International Shipments ❑Import to U.S. ❑Export from U.S. Port of entry/exit. Z Transporter Signature for exports only): Date leaving U.S.: cc w 16.Transporter Acknowledgment of Receipt of Materials ¢ Transporter 1 Printed/Typed Name Signature Month Day Year O CL Cl) Transporter 2 Printed/Typed Name Signature Month Day Year j F i 17.Discrepancy 17a.Discrepancy Indication Space ❑Quantity ❑Type El Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number: H 17b.Alternate Facility(or Generator) U.S.EPA ID Number J I U rai Facility's Phone: LOU 17c.Signature of Alternate Facility(or Generator) Month Day Year a Z O i _ I i 18.Designated Facility Owner or Operator.Certification of receipt of materials covered by the manifest except as noted in Item 17a Printed/Typed Name Signature Month Day Year I I I I