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NONHAZARDOUS 1.Generator ID Number 2 Page 1 of 3.Emergency Respon!a ne 4.Waste Tracking Number <br /> WASTE MANIFEST NOT APPLICABLEJ. <br /> `j 7 (� <br /> 5.Generator's Name and Mailing Address Generalor s Site Address(1 Menotttren mailing address) <br /> . ,7 � �tiX_ �'�/C,, ��/aay x`(31 .:. i�U',/�•��- �. <br /> Generator's Phone: `r�J` /y,�' - f 4 io <br /> 6.Transporter 1 Company Name .f-, ! U8 EPA ID Number <br /> j�i3 /q, /tl/,r, 14-- `` �r�� NOT APPUCABLE <br /> 7.Transporter 2 Company Name k k— US EPA ID Number <br /> PJOT APPLICABLE <br /> e.Designated Facility Name and Ste Addro>fe U.S.EPA ID Number <br /> RECOLOGY HAY ROAD NO t APPLICA13LE <br /> 11"S HAY FbAD - VACAVILLE, CA 9SM7 <br /> I <br /> Facir 's Phone: (7071678-4718 - <br /> 9.Waste Shipping Name and Description t0';ontamers 11.TOW 12 Unit <br /> J No. Type OuerBy WL/Vol. <br /> 1. <br /> cc <br /> uj <br /> 1� <br /> W z. � <br /> i <br /> 3. <br /> 4 <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 labeledlplacarded,and are in at respects in proper condition for transport according to applicable inlematicnal and national governmental regulations. <br /> Generaces/Olferor'sPdntWType-dName _ Signature {_-- <br /> -- Month Day Year <br /> J 15.International hfpmen-4 <br /> ❑Import to U.S. ❑Export from U.S. of entry/exit <br /> — Trans iter S' nature for ex orfs onl): �Oafo leavina U.3.: <br /> ir 16.Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 Printed/Typed Name Signature ( * Month Day Year <br /> h _ <br /> Z Transpoder 2 PrntedlTyped Name Signature Month Day Year <br /> 17.Discrepancy <br /> 17a.Discrepant/Indication Space <br /> ❑Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number. <br /> 17b.Alternate Facility(or Generator) U.S.FPA ID Number <br /> J <br /> U <br /> u- Facility's Phone: <br /> w 17c.Sgnalure of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> z <br /> 0 <br /> U) <br /> 0 <br /> 16.Designated Facility Owner or Operator.t*flcation of receipt of materials covered by the manifest except as noted in Ilem 17a <br /> i <br /> Phnled7yped Name F Signature `% j Month Day Year <br /> 169-BLS-05 11979(Rev.9109) DESIGNATED FACILITY'S COPY r <br /> I <br />