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NON-HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Waste Tracking Number <br /> WASTE MANIFEST NO APPLICABLE ,-V <br /> i 5.Generators Name and Mailing Address Generators Site Address(if dMerent than mailing address) <br /> s r` <br /> .r 11Jo ` <br /> CA 4j'52-45 <br /> Generators Phone: 2-el- to r- <br /> 6. <br /> 6.Transporter 1 Company Name �1 I U.S.FPA ID Number <br /> NOT APPLICABLE <br /> j7.Transporter 2 Company Name U.S.EPA ID NumberNOT APPLICABLE <br /> 8.Designated Fadily Name and Site Address U.S.EPA ID Number <br /> RECOLOGY HAY ROAD 40T APPLICABLE <br /> 3426 HAY ROAD-VACAVII!_E,CA"% i <br /> t Faci s Phone. <br /> 9.Waste Shipping Name and Description 10.Containers 11.TOW 12 Unit <br /> No. Type Quantity WLIW. <br /> 1. <br /> Q <br /> F <br /> w <br /> W 2. <br /> 3. <br /> 4. <br /> 13.Special Handling Instructions and Additional Information <br /> r . <br /> I <br /> i <br /> 'tt /3r'OG Y7 <br /> ' 14.GENERATOR'SfOFFEROR'S CERTIFICATION:I hereby declare that the contents of this consignment are 101 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 intemational and national governmental regulations. <br /> { GeneratorslOflerorS Prinled/Typed_Name Signature Month Day Year <br /> i J 15.International Shipments <br /> I j ❑Import to U.S. ❑Export from U.S. P yd enby/exit rT <br /> Transporter Signature for exports only): i lea U.S- <br /> ix16.Transporter Acknowledgment of Receipt of Materials <br /> w <br /> I- Transporter 1 Pdntedrryped Name t Signa ' Month Day Year <br /> zz Transporter2 Pfintedfryll Name Signatlr. Month Day Year <br /> ;r <br /> 17.Discrepancy / <br /> 17a.Discrepancy Irxllcallon Space <br /> ❑Quantity ❑Type <br /> ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number. <br /> 17b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J_ <br /> l V <br /> ua Facifity's Phone: <br /> w 17c.Signature of Alternate Facility(or Generator) Month Cay Year <br /> z <br /> i <br /> z <br /> N <br /> Lu <br /> D <br /> 18.Designated Facility Owner or Operator.Certification receipt of materials covered by the manifest except as noted in Item 17a <br /> PrioledrTyped Name f //; Signature !� r�; - Month 7Day ,Year <br /> L <br /> 169-BLS-C 5 11979(4ev.9/09) DESIGNATED FACILITY'S COPY <br />