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NON-HAZARDOUS 1 . Generator ID Number 2. Page 1 of 1 3. Emergency Response Phone 4. Waste Tracking Number �— � •i �— <br /> WASTE MANIFEST NOT APPLICABLE <br /> i <br /> 5. etralor's Name apd Mating Address 1 ✓ Generaior�a Re Address (it different than mailing address) <br /> c _ � S3ZL <br /> GeneraloesPhone: 3J , — 5' �- <br /> 6. Transpod/er 1- C Name U.S. EPA ID Number <br /> e-- . ! ;_J �— L) j, ) . L NOT APPLICABLE <br /> 7. Transporter 2 Company Name U.S. EPA ID Number <br /> NOT APPLICABLE <br /> 8. Designated Facility Name and Site Address U.S. EPA ID Number <br /> RECOLOGY HAY ROAD NOT APPLICABLE <br /> 6426 HAY ROAD - VACAVILLE, CA 95687 <br /> Facili 's Phone: (707) 87"716 <br /> 9. Waste Shipping,4Jame and Description 10. Containers 11 . Total 12. Unit <br /> No, Type Quantity WUVol. <br /> ¢ <br /> 1 . <br /> 0 <br /> z 2. <br /> w <br /> 0 <br /> 3. <br /> h <br /> 4, <br /> 13. Special Handling Instructions and Additional Information - - <br /> 75 J <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 /> Generator'slOfferor's PrintedfTyped Nam? Signal" � Month Day Yew <br /> F 15. international Shipments ❑ import to U.S. ❑ Export from U.S. Port of entry/exit: <br /> z <br /> Transporter Signature for exports only): Date leaving U.S.: <br /> ¢ 16. Transporter Acknowledgment of Receipt of Materials <br /> w <br /> Q Transporter 1 Printed/Typed Name Signature Month Day Year <br /> 0 <br /> z Transporter Printedlryped Name Signalure Month Day Year <br /> a <br /> I- <br /> 17. Discrepancy <br /> 17a. Discrepancy Indication Space ❑ Quantity ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection <br /> Manifest Reference Number. <br /> 17b. Alternate Facility (or Generator) U.S. EPA ID Number <br /> J <br /> 0 <br /> LL Facility's Plane: <br /> 17c. Signature of Alternate Facility (or Generator) Month Day Year <br /> w <br /> z <br /> w f^ <br /> n � I <br /> 18, Designated Facility Owner or Operator. Codification of receipt of materials covered by the manifest except as no <br /> Pri a a S to , ' j J Month Day Year <br /> 7 / f t . � , <br /> 169-BLS-C 5 11979 (Rev. 9109) T A SR # 1 <br />