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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 n ; WASTE MANIFEST NQ I�AF'PL.C,A 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) i Generator's Phone: 6.Transporter 1 Company Name U.S.EPA ID Number u. .. . _CCAS 7.Transporter 2 Company Name U.S.EPA ID Number NOT APPLICAPBt 8.Designated Facility Name and Site Address U.S.EPA ID Number ROAD Facility's Phone: 17117)"_ 9.Waste Shipping Name and Description 10.Containers 11.Total 12.Unit No. Type Quantity Wt.Nol. 1. O a cc w Z 2. w 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/Typed Name Signature Month Day Year J 15.International Shipments ❑Import to U.S. ❑Export from U.S. Port of entry/exit: Transporter Si nature for exports only): Date leaving U.S.: r¢ 16.Transporter Acknowledgment of Receipt of Materials GTransporter 1 P' ed(ryped Name Signature Month Day -- Year a Transporter 2 Printed/Typed Name Signature Month Day Year 2 17.Discrepancy 17a.Discrepancy Indication Space ❑Quantity L1 Type El Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number: F 17b.Alternate Facility(or Generator) U.S.EPA ID Number J LL Facility s Phone: a m 17c.Signature of Alternate Facility(or Generator) Month Day Year a 2 :t 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