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NON-HAZARDOUS 1-Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Waste TrackingNumber_/�!] <br /> WASTE MANIFEST NOT APPLICABLE 1 J 3 ! J 4 <br /> 5.Genera�fs Name and Mailing AddressGenerator's Site Address(it different than mailing address) <br /> r <br /> Generator's Phone: <br /> } 6.Transposer 1 Company Name rr U.S.EPA ID Number <br /> NOT APPLICABLE <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> NOT APPLICABLE, <br /> 8.Designated Facf6ly Nacre and Me Address U.S.EPA ID Number <br /> RECOLOGY HAY ROAD NOT APPLICABLE <br /> HAY ROAD - VAC;A%AI.LE, CA 958$7 l <br /> Fail' s Phone: 1 <br /> 9.Waste Shipping Name and Description 1 D.Containers 11.Total 12.Unit <br /> No. Type Ouantily WINoL <br /> 1. 001 <br /> W <br /> W 2. <br /> I <br /> 3 <br /> 4. <br /> 1 <br /> 13.Special Handling Instructions and Additional Infomiafon <br /> i �/39/Y76 <br /> 14.GENERATOR'SIDFFEROR'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 labele#lacarded,and are in all respects in proper condition fortransport according to applicable international and national governmental regulations. i <br /> (Tnerator's/Offeror's Prinled/Typed Name signature ��—a—'"' Y/—) Month Day Year <br /> J 15.International Shipments <br /> i... ❑Import to U.S. ❑Export from U.S. /Port of entry/exit <br /> Transporter Signature for exports only): r Date leaving U.S.: <br /> w 16.Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 PrinledrTyped Name _ Signature MWdh Day yew�, f / 7 <br /> I a L •� _ / rl �� I <br /> I Z Transporter 2 Printed/Typed Name Signature Month Day Year <br /> 17.Discrepancy <br /> 17a.Discrepancy Indication Space <br /> ❑Quantity E]Type, ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number. <br /> 17b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> Q Facility's Phone: <br /> F17c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Z <br /> cs <br /> w <br /> I � <br /> 18.Designated Facility Owner or Operator.Gasification of recep oemaleriats covered by the manifest except as noted in Item 17a,, <br /> Prnted/Typed <br /> 7a - <br /> PrinledYTyped Name f / Signature Month Day Year <br /> / f r <br /> 169-BLS-C 5 11979(Rev.9109) DESIGNATED FACILITY'S COPY <br />