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NON-HAZARDOUS 1.Generator ID Number 2 Page 1 of 3.Emergency Response Phone 4.Waste Tracking Num <br /> bryer p <br /> j WASTE MANIFEST NOT APPLICABLE I J7Q8 <br /> l 5 Generalor's Name and Mailing i n9 Address Generabr's Site Address(if dHerent than mailing address) r <br /> q P�� j%Acln 3�tle�-4& <br /> Generators Phone: �J�(l lt�p '�3 1 1fL' <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> NOT APPLICABLE <br /> I 7.Transporter 2 Company Name U.S.EPA ID Number <br /> NOT APPLICABLE <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> ECOLOGY HAY HQAD <br /> NOT APPLICABLE <br /> =--) `4AY ROAD-VACAVILL.E, CA 95687 <br /> Facill 5 Phone: (70 71 ff78471 R <br /> 9.Waste Shipping Name and Description 10.Containers 11.Total 12,Unit <br /> I <br /> I No. Type Quantity WINoI. <br /> ce <br /> 1 r <br /> I 0 <br /> J , <br /> 077 <br /> w 2. <br /> I <br /> 3. <br /> I <br /> i I <br /> I <br /> 4, <br /> I <br /> i <br /> 13.SpwW Handling Instructions and Additional Information <br /> i <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 labeledlplacarded,and are in all respects in propercondAion for transport acoording to applicable international and national governmental regulations. <br /> Generator's;Offeror's Print edlTyped Name Signature Month Day Year <br /> c, f.,1-n_(' <br /> j 15.International ShipmentsI <br /> E— I ❑Import to U.S. ❑Export from U.S. Port of entry/exit: <br /> Z <br /> Transporter Signature for exports only): r Date leaving U.S.: I <br /> cc 16.Transporter Acknowledgment of Receipt d Materials <br /> U.1 <br /> t— Transporter 1 PrintedlTyped Name. Signature / Month Day Year <br /> i , J <br /> U) <br /> Transporter PrinteryTyped Name — Signature Month Day Year <br /> cc2- <br /> 17.Discrepancy <br /> 17a.Discrepancy Indication Space ❑ ❑Type Quantity yp 11 Residue ❑Partial Rejection Full Rejection <br /> Manifest Reference Number. <br /> 17b.Allernale Facility(or Generator) U.S.EPA ID Number <br /> I <br /> U <br /> rai. Facility's Phone: <br /> W 17c.Signature of Alternate Facility(or Generator) Month Day Year <br /> z <br /> c7 \ <br /> w <br /> o j <br /> 1 B.Designated Facility Owner or Operator:Certificalion of receipt of malerials covered by the mandestexcept as noted in Item 17a <br /> r <br /> ledllyped Name % Signature J �/ Mo Day Year <br /> 169-BLS-C 5 11979(Rev.9/09) DESIGNATED FACILITY'S COPY <br />