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1 <br /> 9 <br /> NONHAZARDOUS 1,Generator ID Number 2 Page 10( 3.Emergency Response Phone 4.Waste Tracking Number <br /> WASTE MANIFEST NOT APPLICABLE 153790 <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> A o_� PA S�c 4e, r0& q �U <br /> Generators Phone: 10 — y - 'v� <br /> e.Transpo ter 1 Company Namei U.S.EPA ID Number <br /> %;N7 4. / �/f cVl — /UL�i%i I.<<. NOT APPLICABLE <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> NOT APPLICABLE. <br /> 8.Designated Facility Name and SM Address U.S.EPA ID Number I <br /> RECA)LOGY HAY ROAD NOT APPLICABLE <br /> j' 64116 HAY ROAD -VACAVILLE, CA SIRW <br /> f Facif s Phone: (7()7jA7P,47JRj <br /> 9.Waste Shipping Name and De6pipbn 10.Containers 11.Total 12 IN <br /> ' No. Type Quantity WWeI. <br /> t. <br /> W 2. <br /> C7 <br /> 4. <br /> I <br /> 13 Special Handling Instructions arid Additional Inforrnwion <br /> 14.GENERATORWOFFEROR'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 governmontai regulations. <br /> Generator s/offeror sI Printed/Typed Name Signature + "'— Month Day Year <br /> j 15.Inlemational Shipments <br /> j... ❑Import b U.S. ❑Export from U.S. Pofffol entrylexit: ' <br /> Transporter Signature for expoets only): Date leaving U.S.: <br /> cc 18.Transporter Acknowledgment of Receipt of Materials <br /> ¢ TranspoApr 1 Printed/Typed S gna i Day Year <br /> Transporter 2 Pdrded/Typed Name Signabirs - Morb1 Day Year <br /> r= <br /> r- <br /> 17.Discrepancy <br /> 17a.Discrepancy Indication Space <br /> i ❑Oua;* ❑Type ❑Residue ❑Partial Rejection ❑Fu8 Rejection <br /> Manifest Reference Number. <br /> t}- 17b.Ahemate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> rai Facility's Phone: <br /> 17c.Signature of Altemate Facility(or Generator) Month Day Year <br /> z <br /> S2 <br /> w <br /> 0 <br /> 18.Designated Facility Owner or Operator:Certification of receipt of materials covered by the manifest except as noted in Item 17a <br /> Pdntedrfyped Name i Signature- Mopth Day Y <br /> 169-BLS-C 5 11979(Rev.9109) DESIGNATED FACILITY'S COPY <br />