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Published by J.J.KELLER&ASSOCIATES,INC.,Neenah,WI•USA•(800)327-6868•www.Ekeller.com•Printed in the United States NON-HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Waste Tracking Number Ir WASTE MANIFEST 1011NAPPLICABLE 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 NST APPLICABLE 7.Transporter 2 Company Name U.S.EPA ID Number NOT AP"tr M-ABLE 8.Designated Facility Name and Site Address U.S.EPA ID Number MC MY MAY ROAD !SOT APPLICASL'E MAYROAD-VACAiMLE,CA 96687' Facil' s Phone: MM 678 718 9.Waste Shipping Name and Description 10.Containers 11.Total 12.Unit No. Type Quantity Wt.Nol. cc 1. O a x w z 2 Lu O 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/Offeror's Printed/ryped Name Signature Month Day Year 1 15.International Shipments z ❑Import to U.S. ❑Export from U.S. Port of entry/exit: Transporter Signature for exports only): Date leaving U.S.: w 16.Transporter Acknowledgment of Receipt of Materials Transporter 1 Printedrryped Name Signature Month Day Year Oa z Transporter 2 Printedlryped Name Signature Month Day Yearcc ' a 17.Discrepancy 17a.Discrepancy Indication Space ❑Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number: >- 17b.Alternate Facility(or Generator) U.S.EPA ID Number J ` U rat Facility's Phone: w 17c.Signature of Alternate Facility(or Generator) Month Day Year a z 18.Designated Facility Owner or Operator.Certification of receipt of materials covered by the manifest except as noted in Item 17a Printed/ryped Name Signature Month Day Year