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(J,�% 6329 <br /> NON-HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Waste Tracking Nunber <br /> WASTE MANIFEST ^`_ill APPLICABLE �53825 <br /> 5.Generators Name and Mailing Address Generators Site Address(d different than mailing address) <br /> C�� ;co S , U4�� ER1�� ,F�p�c 'Lh3t ,-Af IV.1 <br /> Generators Phone: CA 5l j 5 cIG-�o h C� <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> -7,' r a;� 41 OT APFLicasLE <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Des grated Facility Name and She Address hOT APPUC,''_LEU.&EPA ID Number <br /> RECOLOGY FLAY 110AD NOT APPLICA13LE <br /> PA26 NAY ROAD-VACAVILLE,CA VA87 <br /> Facil' s Phone: M 1378471 <br /> 9.Waste Shipping Name and Description <br /> 10.Containers 11.Total 12.Unit <br /> No. Type Quantity WtNol. <br /> cc <br /> 1. <br /> a <br /> ¢ <br /> W <br /> z 2. <br /> WVT <br /> -� <br /> tp <br /> 3. <br /> 4. <br /> 13.Special Handling Instructions and Additional Information <br /> - i <br /> 997,5- <br /> , 14.GENERATOR'S/OFFEROR'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 acccrding to applicable international and national governmental regulations. <br /> Generald0101ferors Printed/Typed Name Signature /r Month Day Year <br /> r/ %1 <br /> _J15.In*national Shipments <br /> F ❑Import to U.S. ❑Export from U.S. Pori of enlry/exit: <br /> Trans orter Signature for exports only); <br /> Dale leaving U.S.: <br /> cc16.Transporter Acknowledgment of Receipt of Materials <br /> ¢ Transporter 1 Prinledryped Name Signature f Month Day Yew <br /> 4-0 <br /> Cn <br /> Transporter 2 Prinledrryped Name Signature Month Day Year <br /> F <br /> 17.Discrepancy <br /> 17a.Discrepancy Indication Space <br /> ❑Quantity El 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 /> rai. Facility's Phone: <br /> W 17c.Signature of Alternate Facility(or Generator) Month Day Year <br /> a <br /> z <br /> y <br /> i w <br /> 0 <br /> I <br /> 16.Designaled Facility Owner or Operator:Cenifiicaiion of receipt of materials covered by the manifest except as noted in Item 17a <br /> Printed/Typed Name n % Signature n iii' Month Day Year <br /> 1 f <br /> 169-BLS-C 5 11979(Rev.9/09) DESIGNATED FACILITY'S COPY <br />