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NON-HAZARDOUS 1•Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Waste Tracking Number WASTE MANIFEST S.tJI1en=fouto Name and Mailing Address Generator's Site Address(if different than mailing address) TP:sq Hurol;, '.i 1 CA fl2M)2 Generator's Phone: ' 6.Transporter 1 Company Name U.S.EPA ID Number 7,Transporter 2 Company Name U.S.EPA ID Number 8.Designated Facility Name and Site Address U.S.EPA ID Number Facili 's Phone: 9.Waste Shipping Name and Description 10.Containers 11.Total 12.Unit 1 No. Type Quantity Wt.Nol. ir a Ir Z 2. w 0 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. Generators/Offeroes Printed/Typed Name Signature Month Day Year J 15.International Shipments �— ❑Import to U.S. ❑Export from U.S. Port of entry/exit• Trans orter Si nature for ex orts onl : Date leavin w 16.Transporter Acknowledgment of Receipt of Materials oTransporter 1 Printed/Typed Name Signature a Month Day Year Z Transporter 2 Printed/Typed Name 16— Signature Month Day Year 17.Discrepancy 17a.Discrepancy Indication Space ❑Quantity ❑Type ❑Residue ❑Partial Rejection 1 El Full Rejection 17b.Alternate Facility(or Generator) Manifest Reference Number: _ U.S.EPA ID Number J V to Facili 's Phone: w 17c.Signature of Alternate Facility(or Generator) ! Month Day Year 0 w 93 16.Designated Facility Owner or Operator:Certification of receipt of materials covered by the manifest except as noted in Item 17a Printed/fyped Name Signature Month Day Yea GENERATOR'S/SHIPPER'S INITIAL COPY