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169 -BLS -C 5 11979 (Rev. 9/09) TRANSPORTER #1 <br />NON -HAZARDOUS <br />1. Generator ID Number <br />2. Page 1 of 3. Emergency Response Phone <br />4. Waste Tracking Number <br />WASTE MANIFEST^}_:� <br />, <br />J <br />5. Generator's Name and Mailing Address Generators Site Address (if different than mailing address) <br />}��� I -� 1 n S <br />�n .i !! rCx CA IU-CAvjS ii; ti L}• ( �1'.l�`� r <br />1 <br />` <br />C (� 1 JC ► �, C-31 11- .r o 1t e 2. Y2 G4 <br />Generators Phone: ` r i `7 - ? („ S -7 3 01. -, —I- < c 1 -r ; ; ,. <br />� C r <br />6. Transporter t Company Name <br />U.S. EPA ID Number <br />li^ vA t v -- <br />?r17T APPLICABLE <br />7. Transporter 2 Company Name <br />U.S. EPA ID Number <br />':CABLE <br />B. Designated Facility Name and Site Address <br />U.S. EPA ID Number <br />J:- - <br />NOT APPLICABLE <br />'. ^3 .!A.Y ROAD - VACAVILLE, C A 95687 <br />Facilil 's Phone: !7,7", 673-4718 <br />9. Waste Shipping Name and Description <br />10. Containers <br />11. Total <br />12. Unit <br />No. <br />Type <br />Quantity <br />WI.Nol. <br />a <br />1. <br />; .... =4a 1 re c, t Y G� CSO o v ._ <br />W <br />Z <br />2. <br />W <br />C7 <br />3. <br />4. <br />13. Special Handling Instructions and Additional Information <br />14. GENERATOR'S/OFFEROR'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 propercondition fortransport according to applicable international and national governmental <br />regulations. <br />Generator's/Offerors Printed/Typed Name Signature <br />Month Day Year <br />ri <br />15. International Shipments <br />❑ Import to U.S. ElExport from U.S. Port <br />F- <br />of entry/exit: <br />— <br />Transporter Signature for exports only): Dale leaving U.S.: <br />16. Transporter Acknowledgment of Receipt of Materials <br />r¢ <br />Transporter 1 Printed/Typed Name Signature / <br />Month Day Year <br />IL <br />Z <br />Transporter 2 Printed/Typed Name Signalure <br />Month Day Year <br />ccI- <br />17. Discrepancy <br />17a. Discrepancy Indication Space <br />❑ Quantity ❑ Type ❑ Residue <br />❑ Partial Rejection ❑ Full Rejection <br />Manifest Reference Number: <br />J <br />171b. Alternate Facility (or Generator) <br />U.S. EPA ID Number <br />U <br />uu.. <br />Facility's Phone: <br />LOU <br />17c. Signature of Alternate Facility (or Generator) <br />Month Day Year - <br />2 <br />C7 <br />N <br />W <br />O <br />1 <br />B. Designated Facility Owner or Operator: Certification of receipt of materials covered by the manifest except as noted in Item 17a <br />Prinle!yped Name Signalure <br />Month Day Year <br />169 -BLS -C 5 11979 (Rev. 9/09) TRANSPORTER #1 <br />