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u tb "L <br /> NONHAZARDOUS 1 . Generator ID Number 2. Page i of 3. Emergency Response Phone 4. Waste Tracking Number 1 Q y /- O Q <br /> FEST <br /> WASTE MANINOT APPLICABLE Q V 1.i v a <br /> 5. Generator's Name and Mailing Address Generator's Site Address (it different than mailing address) <br /> Generatoes Phone: <br /> 6. Transporter 1 Company Name U.S. EPA ID Number <br /> NOT APPLICABLE <br /> 7. Transporter 2 Company Name U.S. EPA ID Number . <br /> NOT APfnJCABLE <br /> 8, Designated Facility Name and Site Address U.S. EPA ID Number <br /> RECOLOQIY HAY ROAD NOT APPLICABLE <br /> 6426 HAY ROAD - VACAVILLE, CA 95687 <br /> Facii s Phone: 678.4718 <br /> 10. Containers 11 , Total 12, Unci <br /> 9. Waste Shipping Name and Description <br /> No, Type Quantity WtNol. <br /> 1 . <br /> U — <br /> H T — <br /> W <br /> w 2. <br /> 0 <br /> 3 . <br /> 4. <br /> 13. Special Handling instructions and Additional Information - - <br /> 1 - <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, packagedIYear marked and labeledfplacarded, and are in all respects in proper condition for transport according to applicable international and national governmental regulations. <br /> Generators/Offero(sPdntedrTypedName �j Signature � %' Month Day <br /> 15, International Shipments 4 <br /> i ❑ Import to U.S. ❑ Export from U.S. Port of entry/exit <br /> z <br /> Transporter Sinature fore Date leaving U .S.: <br /> cc 16. Transporter Aclmowledgment of Receipt of Materials _ <br /> ¢ Transporter 1 Prinled/fyped Name y ! Signature M� Day Year <br /> z Transporter 2 Prinled/fyped Name Signature Month Day Year <br /> a <br /> cc <br /> 17. Discrepancy <br /> 17a . Discrepancy Indication Space ❑ OuanNy ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection <br /> Manifest Reference Number: <br /> F>- 17b. Aftemate Facility (or Generator) U.S. EPA ID Number <br /> U <br /> LL Facilitys Phone: <br /> w 17c. Signature of Alternate Facility (or Generator) Month Day Year <br /> r - <br /> a <br /> z <br /> 0 <br /> 18. Designated Facility Owner or Operator. Certification of receipt of materials covered by the manifest except as noted in Item We <br /> Printedrfyped Name f Signature Month Day Year <br /> ' C? 6 I ' <br /> 169 - BLS-05 11973 ( flev, 9/99) TRANSPORTER # 2 <br />