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f <br /> t.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Waste Tracking Number <br /> NON-HAZARDOUS <br /> WASTE MANIFEST i` '' PPUCABLE i -.14826 <br /> 5.Generators Name and Mailing Address Generators Site Address(9 different than mailing address) <br /> I, / i <br /> C 0.1 -�rav►� 'tN0 No 31 1 oo4 11.3 f E, �GCi'�k3sA P' � <br /> 35 V. A-re4tl R� �I%k�j (-A 95215 vc 1 <br /> Generators P�: - J ^""n 6A <br /> 6.Transporter 1 Company Name J U.S.EPA ID Number <br /> NOT APPLICABLE <br /> 7.Transpo er 2 Company game ' U.S.EPA ID Number <br /> A, NOT APPUCABLE <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Nw*w <br /> RECOLOGY NAY"ROAD <br /> NOT APPLICABLE <br /> , X26 WAY ROAD-VACAVILLE,CA VA87 MAR 0 3 2015 <br /> Fad sPhone: (7671978-4718 <br /> 10.Containers <br /> 9.Waste Shipping Name and Description ENVIRON 11.Total i 2 Unit <br /> r:.-. �],r •,.-at No. Type Quantity WWol- <br /> cc 1��- <br /> a <br /> cc <br /> W <br /> z <br /> W 2. <br /> 3. <br /> 4. <br /> 13.Special Handling Instructions and Add tional Information <br /> - i <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 labeledtplacarded,and are in all respects in proper condition for transport according to applicable international and national govemmenlal regulations. <br /> Genaratoes/Offerors Printed/Typed Name Signature Month Day Year <br /> 15.International Shipments <br /> ❑Import to U.S. ❑Export from U.S. Port of entry/exit <br /> Transporter Signature for exports only): Date lea* U.S.: <br /> m 16.Transporter Acknowledgment of Receipt of Matedals <br /> Transporter 1 Printed/Typed Name Signature ,r Month Day Year <br /> z Transporter 2 P ntedlyped Name Signature j Month Day Year <br /> 17.Discrepancy <br /> 17a.Discrepancy Indication Space <br /> ❑Quantity ❑Type ❑Residue ❑Partial Rejection El Full Rejection <br /> Manifest Reference Number <br /> 17b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> U <br /> a Facifity's Phone: <br /> 17c.Signature of Altemale Facility(or Generator) Month Day Year <br /> a <br /> z <br /> 2 <br /> 0 <br /> W <br /> O <br /> 18.Designated Facility Owner or Operator:Certification of receipt of materials covered by the manifest except as noted in Item 17a <br /> Printed(ryped Name — / r Signature / f Month Day Year <br /> 169-BLS-C 5 11979(F&V.9109) DESIGNATED FACILITY'S COPY <br />