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NON-HAZARDOUS 1.Generator ID Number 2.Pa go 1 of 3.Emergency Response Phone 4.Waste Tracking Number <br /> WASTE MANIFEST NOT APPLICABLE 153797 <br /> 5.Generator's Name and Mailing Address Generators Site Address(f different than mailing address) <br /> /1 EA/u �AlLbr <br /> -54- <br /> Generators Phone <br /> r V <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> NOT APPLICABLE <br /> 7.Transporter 2 Company Name U.S.EPA ID Karim <br /> f <br /> NOT APPUCABL E <br /> 8.Designated Facility Nerve and Sis Address U.S EPA ID hturtber <br /> ,"COLOGY HAY ROAD NOT <br /> "25 NAY ROAD- VACAVILLE,CA 95N7 <br /> Facili s Phone: (707)678-4718 <br /> 9.Waste Shipping Name and Desaip6on 10.Containers 11.Total 12.Unit <br /> No. Type Quantity WtNol. <br /> ¢ 1. <br /> a <br /> Tt l 9 7 ( l/ <br /> w <br /> z 2. <br /> w <br /> (7 <br /> i <br /> 3, <br /> 4. <br /> 13.Special Handling Instructions and Additional Information <br /> /3 Y7 <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 labeled/placarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations. <br /> GeneratofslOfferor's Printed/Typed Name Signature t"' Month Day Year <br /> F 15.International Shipments ❑Import to U.S. ❑Expert from U.S. P of entry/exit <br /> Trans orterSl nature for exports onlateleavi U.S.: <br /> Cr W 16.Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 Pratt rvTyped Name SigtaNle Month Day Year <br /> Transporter 2 PrinteNryped Name Signature Month Day Year <br /> t- <br /> 17.Discrepancy <br /> 17a.Discrepancy Indication Space <br /> ❑Quantity ❑Type ❑Residue El Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 171b.Altemate Facility(or Generator) U.S.EPA 10 Number <br /> _I �I <br /> rill Facility's Phone: <br /> w 17c.Signature of Alternate Facility(or Generator) Month Day Year <br /> F <br /> ' a <br /> z <br /> 0 <br /> rn <br /> w <br /> 0 <br /> 1 B.Designated Facility Owner or Operator.Certification of receipt of materials covered by the manifest except as noted in Item 17a <br /> Pr 10'ryped Name Signature Month Day Year/ <br /> 169-BLS-C 5 11979(Rev.9/09) DESIGNATED FACILITY'S COPY <br />