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PDX ft 3,),q <br /> NON-HAZARDOUS 1,Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Waste Tracking Number <br /> WASTE MANIFEST NOT APPLICASLE �� l <br /> 5.Generalor's Name and Mailing Address Generator's Site Address(it different than mailing address) <br /> 'I <br /> Gene rebfs Phone: 2 <br /> I <br /> 6.Transporter 1 Company Name / U.S.FPA ID Number <br /> I, ��i f��r,, �` f f�c'__ NOT APPLICABLE <br /> i 7.Transporter 2 Company Name U.S.EPA ID Number <br /> NOT APPLICABLE <br /> B.Designated Facility Name and Site Address U.S.EPA ID Number <br /> ECOLOGY H."kY ROAD NOT APPLICABLE <br /> F iAY ROAD-VACAVILLE,CA 95M <br /> Fadi s Phone: — 03711471 <br /> 1 <br /> 9.Waste Shipping Name and DescfIf" 10.Containers 11.Total 12.Unit <br /> No. Type Quantity WL/Vol. <br /> 1. <br /> 105 1 <br /> I <br /> w 2. <br /> I <br /> 3 <br /> 4. MPR� <br /> 13.Special Handling Instructions and Addrtlonal Information <br /> 1 <br /> �/35aaFs� <br /> 14.GEN ERATOR'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 attending to applicable international and national governmental regulations. <br /> Generalcies!Olferor's Printed/Typed Name Signature Month Day Year <br /> c <br /> I J 15.InternationalShipfnents <br /> i— ❑Import to U.S. U Export from U.S- Port of entry,exit <br /> Z Transporter Signature for ex oRs only): Date leaving U.S.: <br /> cc 16.Transporter Acknowledgment of Receipt of Malerials <br /> Transporter 1 PrIntedrTyped Name Signature 1 4' Month Day Year <br /> EL <br /> cTransporter 2 Printed/Typed Name Signature Month Day Year <br /> 17.Discrepancy <br /> 17a,Discrepancy Indication Space <br /> ❑Quantity ❑Type ❑Residue El Partial Rejection Full Rejection <br /> Manifest Reference Number. <br /> T 1 i b.Allemate FacHity(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> LL Facility's Phone: <br /> QQ 17c.Signature of ABernata Facility(or Generator) Month Day Year <br /> 2 <br /> w <br /> W <br /> O <br /> 1 <br /> I <br /> 18.Designated Facility Owner or Operator.Certification of receipt of materials covered by the manifest except as noled in Item 17a <br /> j Printed?�gdName Signature Mouth Day: Yw <br /> f� I <br /> I <br /> 169-BL&Z 5 11979(Rev.9/091 DESIGNATED FACILITY'S COPY <br />