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169 -BLS -C 5 11979 ((OOur. 9/09) v TRANSPORTER #1 <br />NON44AZARDOUS <br />1. Generator ID Number <br />2. Page 1 of <br />"3. Emergency Response Phone <br />4. Waste Tracking Number ^ <br />► <br />WASTE MANIFEST <br />NOT APPLICABLE <br />S. G('nerator's Name and Melling Addras; a Generaioes Sha Address Cif different then mating address) <br />A C�+4. 1 <br />GPrfAfet6lsPhone: l C 1 ASA Tn CSC �,0CJ C <br />6. Trdheportef 1 Company Name U.S. EPA ID Number <br />NOT APPLICABLE <br />7. 779spotTer 2 Company Name U.S. EPA ID Number <br />NOT A _ CAS <br />8. Designated Facility Name and She Address U.S. EPA ID Number <br />RECOLOGY HAY ROAD' NOT APPLICABLE <br />6426 HAY ROAD - VACAVILLE, CA 9M7 <br />Fac3 s Phone:(MZ) 67&4718 <br />9. Waste Shipping Name and Description10. <br />Contelners <br />11. Total <br />Quantity <br />12. Unit <br />WWoI. <br />fJc. <br />Type <br />r <br />' <br />1 <br />r/5 <br />� /q <br />F � <br />��Ib tv�.. fo'n't y •'r���� `1 i <br />i• <br />3. <br />y"a <br />4. <br />?rat �' <br />- <br />+t�:�•Y"��`s11�:���'r� <br />13. Special Handing Mtructions andAdddional Information <br />14. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the cantenis of this consignment are filly and accuratety described above by the proper shipping name, and are classified, packegod, <br />marked and labeledlptacarded, and are In of respects in proper conddlari for Inrnspoa according to applicable "ernatlonal and emmentai regulations. <br />GeneratoeelOffoices Pdnledayp e 4 <br />Signature Month Day Year <br />15. international Shipments <br />Import toU.S. F,rpod from U.S. Port of entrylexR: <br />Transporler Signature for exportsa Data laavtnq. U.S.: <br />16, Transporter Adu+nwledgment of Recept of Materials r <br />Traneoolter 1 Printeryped Name Signature Month Day Year' <br />a <br />o12 <br />1 , f <br />Transporter 2 PdritedlTyped N Signature Month' Day Year <br />17. DiuMancy <br />17a. Discrepancy indication Space ❑ Ouantily ❑ Type ❑ Residueftion Ful Rejection <br />❑ Partial Rd ❑ Ilan <br />q <br />Menhest Reference Number. <br />17b, Alternate Facility for Generator) U.S. EPA ID Number <br />a <br />rat <br />Facility's Phone: <br />17c. Signature of Alternate Facility (or Generator) tylandh Day Year <br />'.;r;- •i��F�y <br />y p air _k r; 4�• ,- <br />fat £ doe S iF . +r -.k <br />,r?'•�rrta '�''`f!•ara rat- 4rs;:t <br />�h�,?� J�,.. y T;r, yx -�' �. <br />Sr"fakyji. is 3j., _�,rr:< •fh�`�,: <br />� <br />p. <br />a :t'�` f�'. <br />w•i( ��G��"�3�i�.. .•}•; a, <br />2 'e. '�;'Y �R� •��' t7 �i�'t �'�s�1 - �-��,��, M� L1jU'' tr <br />'".ft:��ki ''�t.Ya <br />,t'��Y <br />�dwL,Aw �}.: 7.- c a}. �: '�!(, .t• !h1't �'�" -. j`i:: r ;4 0.''.�+�.c <br />�,'.�:?k Tf:. .tN :4�`vY i•: er1, A - o i . ;x'.14 <br />18. Designated Facility Owner or Operator. Certification of receipt o1 materials covered by the manifest except as noted In Item 17a <br />PdnledfTyped NameS gnalure Month Day' v Ye L &:!, Out , —1 1 Z�, 1 :7 1_—:� <br />169 -BLS -C 5 11979 ((OOur. 9/09) v TRANSPORTER #1 <br />