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I NONHAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Waste Tracking Number(� <br /> WASTE MANIFEST NOT APFUCABLE 1 J 3 8 Q 1 <br /> S.RGeneqtDrs Name and Marling Address 1 O Generators Site Address(if ddferenl than mailing address) <br /> Generators Phone: 2 �y <br /> 6.Transporter t Company Name ! U.S.EPA ID Number/'� � A, .,,l(e-y lw e-tf 'i [. c— NOT APPLICABLE <br /> 7.Transporter 2 Company Name (_ U.S.EPA ID Number <br /> W)r APPLICABLE <br /> 1 <br /> B.Designated Faclity Name and Site Address U.S.EPA ID Number <br /> RECOLOGY HAY ROAD NOT APPLICABLE <br /> '( 642H HAY ROAD- VACAVILLE.CA'?M7 -- <br /> F s Phone: U071 678471 A <br /> 9.Waste Shipping Name and Descdption 10.Conlalners 11.Total 12 Unit <br /> No. Type Quantity WWd. <br /> i cc 1. <br /> 0cc <br /> i- I <br /> W <br /> �- r = <br /> Z 2. <br /> W <br /> 0 <br /> 3. <br /> to3L <br /> 4. <br /> 13.Special Handing Instructions and Additional Information <br /> 14.GENERATOR'S/OFFEROR'S CERTIFICA71ON:I hereby declare that the contents of this consignment are fully and accuralefy described above by the proper shipping name,and are classified.packaged, <br /> marked and labelecilplacarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations. i <br /> Generator'slOflerors Prinlcd yped Name Signatur Month Day Year <br /> IS.Intema8or Shi nls <br /> P ❑Import to U.S. ❑Export from U.S. Port of entry/exit: <br /> Transporter S'nature fore orts only); r Date lea U.S.: <br /> Lu 1&Transporter Aduwwledgment of Receipt of Materials <br /> Transporter 1 I'MtedRyped Name Signature `rs Month fpay Year' <br /> -j ' <br /> 3 <br /> Transporfer 2 Printedlryped Name Signature (r' Month Day Year <br /> 17.Discrepancy <br /> 17a.Discrepancy Indication Space <br /> ❑Quantify ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> I <br /> Manifest Reference Number. <br /> F 17b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> i U <br /> uu.. Facility's Piton: <br /> Lou 17c.Signature of Alternate Facility(or Generator) Month Day Year <br /> a <br /> z I <br /> Go <br /> W <br /> 0 <br /> 18.Designated Facility Owner or Operator.Certification of receipt of materials covered by the manifest except as noted in Item 17a <br /> Printed(fypedName ���� l Signature _ �� Month Day Year <br /> 169-BLS-05 11979(Re%/9109) DESIGNATED FACILITY'S COPY <br />