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NON -HAZARDOUS WASTE MANIFEST <br />Please print or type (Form designed lot use on shut t12 pitch) typewriter) <br />CF14 02002 LAst:LAAsrex® ( <br />NON-HAZARDOUS <br />`fr.Tk(>i�i!Pl"d, <br />1 <br />Manifest€'sttlC!?t!9 <br />2.Page1 <br />WASTE MANIFEST <br />17ocumentNo. <br />of <br />_ <br />P&gg0rtrBft Rand Mailing Address <br />_ <br />21{201 ��FfYs�awQ11aI:a AN;a. <br />_F= <br />Sh il*410 t, CA 95201 <br />e6 <br />_= <br />M�i�1-bill 3fk}� <br />-- <br />4. Generator's Phone ( } <br />n 1 m y ) b. <br />f�,�i...i�&fF9fF~�1'�-�t}��it�t kis;:, (��. j <br />US EPA <br />��i.'�i1tKi{}7t3��1i} <br />A. State Transporters ID <br />Viz= <br />_ <br />B. Transponer 1 Phone <br />— = <br />7. Transporter 2 Company Name 8, <br />US EPA ID Number <br />C. State Transporters ID <br />D. Transporter 2 Phone <br />esignated Facild ama at (te dpr t0. <br />R,trr1� Grxaatlapttnrsa I <br />US EPA ID Number <br />E. State Facility's ID <br />i:A111003902D <br />- <br />2-1739 deed 14 PJAIr'riwa tnaft!! <br />l.;l1owd 0a, GA8UID <br />F. Facility's Phone rl5t},. �ttyi <br />M <br />ti. WASTE DESCRIPTION <br />Containers <br />13. <br />14. <br />- <br />Total <br />Unit <br />�_No. <br />Typo <br />Ouentlty <br />Wt.Nol. <br />_*fJtj <br />n Hit VVrs.a <br />C314A <br />Y <br />=- <br />G <br />b. <br />E <br />N <br />E <br />R <br />c. <br />A <br />T <br />O <br />R <br />d. <br />G. Additional Descriptions for Materials Listed Above <br />H. Handling Codes for Wastes Listed Above <br />15. Spacial Handling instructions and Additional fnfdfamo d Nt!mber 865!9 <br />MEW A—W <br />beirtiffla li t: V-11100709 <br />; <br />NIL <br />16. GENERATOR'S CERTIFICATION: 1 hereby certify (hat the contents of this shipment are fully and accurately described and are In all respocis <br />In proper condition for transport, The materials daacribed on this manliest are not subject to federal hazardous waste rogulatlon% <br />to <br />Data <br />F <br />Prinledfiyped Name j �. <br />Signature,( r l <br />Month <br />Day Year <br />T <br />17. Transporter 1 Acknowledgement of Receipt of Materials <br />I 1 <br />Date <br />R <br />A <br />Printed, -Typed Name <br />Signature <br />Month <br />Day Year <br />N <br />S <br />S <br />` <br />i .5 <br />O <br />18, Transporter 2 Acknowledgement of Recelpt of Materials <br />Date <br />R <br />T <br />Pr(nted?ypod Name <br />Signature <br />Month <br />pay Yaer <br />E <br />R <br />19- Discrepancy Indication Space <br />A <br />C <br />1 <br />20 Facifity Opener or Operator: Certification of receipt of the waste materials covered by this manifest, except as noted In item 19. <br />! <br />Date <br />T <br />Pdnted,Typed Name <br />Signalum <br />Month <br />pay Year <br />Y <br />800)621.5808 www.labelmastor.com <br />W t ,!swtrrx <br />