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NON-HAZARDOUS 1,Generator ID Number 2 Page 1 of 3.Emergency Response one 4.Waste Track ng Number <br /> WASTE MANIFEST NOT APPL(CABLG 5381 i <br /> 5.Generalor's Name and Mailing Address Generatofs Site Address(if different than mailing address) <br /> 431 <br /> Act l_ /'Q <br /> GeneratofsPhone 7 q - qG(� '� k7�Vi r/Tl <br /> 6.Transporter 1 Company NameU.S.EPA ID Number <br /> _i ;', ' �t i�`G ( <br /> r �i�1 Itt Vi C- NOT AF"+ICABLE <br /> , " <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 /> i RE(X.LC GY HAY ROAD NOT APPLICABLE <br /> i P42%3 HAY ROAD- VACAVILLE,CA V-687 <br /> Facili s Phone: 7 <br /> 9.Waste Shipping Name and Description 10.Containers 11.Total 12.Unit <br /> No. Type Quantity Wtivol. <br /> cc <br /> 1. <br /> Q �• �r �y7\' t_.�I•ilk.- t✓� 1(�. ^t <br /> W <br /> Z 2. <br /> w <br /> 3. <br /> n q <br /> i n�`� <br /> M <br /> 13.Special Handfmg Instructions and Addlliorraal Information-" <br /> #/ 9 oir6 <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 /> Generalor's/Of,erofs Printed/Typed Name Signature Month Day Year <br /> is <br /> 15.International Shipments <br /> ❑Import to U.S. []Export from U.S. Pbrt of entry/exit: <br /> Transporter Signature for exDorls only): __ Date leaving U.S.: <br /> w 16.Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 Pr yped N Signature 4 y , Month Day Year <br /> on iz r <br /> Transporte 2 PrinlerLTyped Name Signature Month Day Year <br /> I ~ — <br /> 17.Discrepancy <br /> 17a.Discrepancy Indication Space <br /> ❑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 />� U <br /> LL Facility's Phone: <br /> m 17c.Signature of Aitemale Facility(or Generator) <br /> H Month Day Year <br /> a <br /> Z <br /> t7 <br /> co <br /> W <br /> r] <br /> 18.Designated Facility Owner or Operator.Certification of receipt of materials covered by the manifest except as noted in Item 17a _ <br /> Pdnted/fyped Name ' " ! Signature _ Month Day Year <br /> 169 BLS-C 5 11979(Rev. /o9) _ DESIGNATED FACILITY'S COPY <br />