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NONHAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Waste Tracking Number WASTE MANIFEST 5,Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) - Generators Phone: 6.Transporter 1 Company Name U.S.EPA ID Number EPA ID Numbe r er ` 7.Transporter 2 Company Name U.S. • 8.Designated Facility Name and Site Address U.S.EPA ID Number -!40N tr Rd 2W" r.... .f 'A.. 95776 Facility's Phone: 1 ��"��` 10.Containers 11.Total 12.Unit 9.Waste Shipping Name and Description No Type Quantity Wt.Nol. 1. .s, .•ilr' O a I ¢ w Z 2. w C7 3. 4. 13. Special Handling Instructions and Additional Information CeS C ,tem I rand hat t► 7pM 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. ;QM Generator's/Offerors Printed/Typed Name Signature Month Day Year 15.International Shipments T F ❑Import to U.S. ❑Export from U.S. Port of entry/exit- Transporter Signature for exports only): Date leaving U.S.: 3 C ac 16.Transporter Acknowledgment of Receipt of Materials LU 11,_ Transporter 1 Printed/Typed Name Signature Month Day Year O a aTransporter 2 Printed/Typed Name Signature Month Day Year x t- 17.Discrepancy 17a.Discrepancy Indication Space Quantity ❑Type El Residue ❑Partial Rejection ElFull Rejection r, I Manifest Reference Number. 17b.Altemate Facility(or Generator) U.S.EPA ID Number _J V Z Facili 's Phone: 0 17c.Signature of Alternate Facility(or Generator) Month Day Year W Q Z 0 C w 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 GENERATOR'S/SHIPPER'S INITIAL COPY