Laserfiche WebLink
'' I <br /> i <br /> NON-HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Waste Tracking Number <br /> -y <br /> WASTE MANIFEST NOT APPLICABLE �.;�� 1 7� <br /> S.Generator's Name and Mailing Address Generator's Site Address Q1 dikren t than mailing add) ' <br /> ��.{ ��� f•',~/� �lGv'jF ��:�i l �= t'tA"-ono S� <br /> 2 �P� 129. 5{r�� >�_ GA 9S2'S <br /> Generator's Phone: L''9' <br /> 6.Transporter 1 Company Name ✓ . <br /> U.S.EPA ID Number i <br /> NOT APPLICABLE �. <br /> j 7.Transporter 2 Company Name ( U.S FSA ID Number <br /> APPUCABLE <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> RECOLOGY HAY ROAD tiO7 APPLICABLE- <br /> 6426 HAY ROAD-VACAVILLE, CA 95687 j <br /> Facifil es Phone. 1170Z)67 <br /> 10.Containers 11.Total 12 Unit <br /> 9.Waste Shipping Name and Description No Type OuartMy WL/Vol. <br /> I <br /> O — <br /> W - <br /> W 2. <br /> tl <br /> 3. <br /> MA Olt <br /> 4. <br /> ENVIP <br /> 13.Special Handling Instructions and Additional Information <br /> 14.GENERATOR'S/OFFEROR'S CERTIFICATION:I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and labeledtplacarded,and are in all respects in proper condition for transport according to applicable intemational and national governmental regulations. <br /> GeneralofsMerors PrintedlTyped Name Signature ; Month Day Year <br /> _1 15.International Shipments r V IF <br /> FZ ❑Import to U.S.~ ❑Export from U.S. Port of entrylex t <br /> Transporter Signature for exports only): bate leaving U.S.: <br /> ¢ 16.Transporter Acknowledgment of Receipt of Materials <br /> Transposer 1 Printed/Typed Name Signature Month Day Year <br /> a <br /> Z Transporter 2 Printed/Typed Name Signature Month Day Year <br /> 17.Discrepancy <br /> 17a Discrepancy Indication Space <br /> ❑Quantity ❑Type ❑Residue ❑Partial Rejection Full Rejection <br /> Manifest Reference Number. <br /> 17b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> U. Facility's Phone: <br /> 17c.Signature of Alternate Facility(or Generator) Month Day Year <br /> a <br /> z I <br /> W <br /> C1 <br /> 18.Designated Facility Owner or Operator:Certification of receipt of malierials covered by the manifest except as noted in Item 17a <br /> PrinledlTyped Name / l- Signature Month Day Year <br /> ( / I 1 r <br /> 169-BLS-C 5 11979(Rev.9109) r/ DESIGNATED FACILrrY'S COPY <br />