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NON-HAZARDOUS I.Generator ID Number 2 Page 1 of 3.FJnergency Response Phono 4.Waste Tracking Number g�rn� <br /> WASTE MANIFEST 1401 APPUCABLE .�C3U <br /> 5.Generators Name and Mailing Address Generators Site Address(d different than mailing address) <br /> j , ,�4. Oc9 5 orf k �ci. c�� S 7_t c <br /> Generators Phone: U 9 <br /> 6.Transporter 1 Comparry Name U.S.EPA ID Number <br /> ,•t' _ jZ��K- `lam �'-� c_ . 0T AI.Pi;CABLE <br /> 7.Transporter 2 Company Name U.S.EPA ID Nurriber <br /> NOT APPLICABLE <br /> 8.Designated Facility Name and Sds Address U.S.EPA ID Number j <br /> RECOLCOY HAY ROAD <br /> NOT APPLICABLE <br /> :J?5 HAY ROAD -VACAVILLE, CA 95W7 <br /> Facility's Phone: <br /> 9.Waste Shipping Name and Description 10.Containers 11.Total 12.Unit <br /> W. Type Ouardy, WL/VOL <br /> 1. / ? <br /> w <br /> W 2. <br /> C7 <br /> 3. <br /> 4. <br /> 13.Special Handfiing Instructions and Additional Information <br /> 4 >f <br /> �/.3 50706 <br /> ! 14.GENERATOR'S/OFFEROR'S CERTIFICATIOR-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 labeled/placarded,and are in all respects in proper condition for transport according to applicable international and national govemrnental regulations. <br /> Gene alors101feror s PrintedlTyped Name_ Signature Month Day /Year <br /> 1 15.International Shipments r ❑Im t to U.S. ❑ PoA <br /> 2 po Export from U.S. of eniry,'ex1 i <br /> Transporter Sionatura for ex arts only): Date leaving U.S.: <br /> w 16.Transporter Acknowledgment of Receipt of Malerials <br /> w <br /> Transporter 1 PrintediTyped Name Signature Month Day Year <br /> Ir <br /> Transporter 2 PrinledrTyped Name Signature Month Day Year <br /> 17.Discrepancy — <br /> 17a.Discrepancy Indication Space ❑ <br /> � Quantity <br /> El Type ❑Residue ❑Partial Rejection ❑Full RejeGGion ! <br /> Manifest Reference Number. <br /> 17b.Aliemate Facility(or Generator) U.S.EPA ID Number <br /> u. Facility's Phone: <br /> 17c.Signature of Alternate Facility(or Generator) Month Day Year <br /> z <br /> I w <br /> 18.Designated Facility Owner or Operator.Certification of receipt of materials covered by the manifest except as noted in Item 17a <br /> PrinledfTypedName f j Signature1 �) J Year <br /> ! 169-BLS-C 5 11979(Rev.9109) ✓ \ j DESIGNATED FACILITY'S COPY <br />