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14 <br /> :;NO�N-4HAZARDOUS1•Generator ID Number' 2 Page 1 of 3.Emergency Response Phone 4.Waste Tracking Number <br /> NOT APPLICABLE 153195 i. (Q�C <br /> ' 5.Generators Name and Mailing Address Generators Site Address(if different than mailing address) <br /> < l :AIG1k/rUrf �7 r <br /> Q.� �.- � 5' �- C.l� f'�1_I� '-I,�,t 1.• r1.��..-s i ;% ..._ _. j1-c:L <br /> Generator's Phone: <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> •-'r11 `' NVIM' t<U�' (,�r 1 /l.c-- i�lO; ,�iNF'LiCABLE <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> NOT APPUGABLE' <br /> B.Designated Fac:Qy Name and Sile Address U.S.FPA ID Number I <br /> RECOLOGY HAY ROAD lrl i APPUCASLE <br /> ��#?5 HAY ROAD -VACAVUE,CA 9W87 <br /> Fact s Phone: C7071 _ f <br /> Containers <br /> 9.Waste Shipping Name and Description 10. 17.Total 12.Unit <br /> No. Type Quanlity, WtNol. <br /> 1. <br /> ¢O I <br /> Z 2. C <br /> w <br /> tl I <br /> I <br /> I <br /> rr <br /> 4. N;1 <br /> • <br /> 13.Special Handling Instructions and Additional Information <br /> i <br /> `/39/s// <br /> 14.GENERATOR'SIOFFEROR'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 laboledrplacarded,and are in an respects m proper condition for transport according to applicable international and national governmental regulations. <br /> Generatorsi0flerors Pdnle&7yped Name Signature / ��— Month Day Year <br /> _._. <br /> ...r 15.Irrtemational Shipment / <br /> 2 I El 1"P.4 to U.S. ❑Export from U.S. Foil of enlry/exit <br /> Transporter Simature for exports only): Dale leaving U.S.: <br /> Ir 16.Transporter Acknowledgment of Receipt of Materials <br /> Transporter i Printed/Typed Name Signature -n Month Day Year <br /> Q Transporter PrintedrTyped Name Signature Month Day Year <br /> F <br /> ir <br /> 17.Discrepancy <br /> i 17a.Discrepancy Indication Space E]T e <br /> I ❑Quantity Type El Residue ❑Partial Rejection ❑Full Rejection <br /> I <br /> Manifest Reference Number. <br /> 17b.Aftemate Facility(or Generator) U.S.EPA ID Number <br /> V <br /> rQi Facility's Phone: <br /> w 17c.Signature of Alternate Facility(or Generator) Month Day Year <br /> r— <br /> Q <br /> I Z <br /> S2 <br /> rn <br /> w <br /> 0 <br /> I <br /> 16.Designated Facility Owner or Operator.Certification of receipt of materials covered by the manifest except as noted in Item 17a <br /> Printedriyped Name Signature Month Day Year <br /> 169-BLS-C 5 11979(Rev.9109) DESIGNATED FACILITY'S COPY <br />