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NON-HAZARDOUS 1.Generator ID Number 2 Page 1 of 3.Bnergency Response Phone 4.Waste Tracking Nurnbrr ; <br /> 1 WASTE MANIFEST '.'J APPLIGABLE �5 3820 <br /> I 5.Generators Name and Mating Address Generalor's Site Address(d different than mailing address) <br /> C0. -cY a^s �" e Nk0 2431 5W E". r )CJ- <br /> Art sa <br /> >�i(oZ Anti lCd• �llx,'rnn �� <br /> i Genaafora Pirorte: - � <br /> 95 15 CA ;. <br /> 6.Transporter f Company Name U.S.EPA ID Number <br /> iAA �0.n��i i n C • WT APPUONKE I. <br /> i <br /> 7.Transporter Company Now U.S.EPA ID Number <br /> NOT APPLICABLE <br /> 8.Designated Facility Name and Site Address j U.S.EPA ID Numbs <br /> RECOLOGY HAY ROAD ! NOT APPLICABLE <br /> C'-F) HAY ROAD- VACAVILLE,CA sssaPA2 03 2015 <br /> -FactV(sPhonet (707)87&471A <br /> ENVIRONMEN IAL to. <br /> Conlainers 11.Total 12 Unit <br /> 9.Waste Stdppng Nene and Desalp0an ' <br /> No. Type Orrantity WWot � <br /> w <br /> rz P. C <br /> W <br /> z 2. <br /> w <br /> C7 <br /> 3 <br /> 4 — -- - <br /> 13.Special Herift and Add6mal lydomutlon — <br /> L v e; ry <br /> i <br /> i3 9 oos s <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 n proper condition for transport according to applicable international and national governmental regulations. <br /> Generatoes"aror's PrinledrTyped Name ) Signature ' �- Month Day <br /> Year <br /> .�►'!`r..r .J C�-1 C�r•F7�_r .14�-r� C`�'�NV1.e. I C./ J=. <br /> J 15.International S*menIs <br /> F ❑Import to U.S. ❑Export from U.S. 'Port of entry/exit <br /> Transporter Signature for exports only): _ Date leaving U.S.: <br /> cr 16.Transporter Admowledgmenl of Receipt of Materials <br /> F <br /> Transpoderl Printed/iyp=_d Name Signature �� Mongt Day Year <br /> cc <br /> O <br /> aTransporter 2 PrintedlTyped Name Signature Mordh I Day Year <br /> ~ LL <br /> 17.Discrepancy <br /> 17a.Discrepancy Indca6on Space <br /> ❑Quantify ❑Type ❑Residue ❑Partial Resection Full Rejection <br /> Manifest Reference Number <br /> T 17h.Alternate FacBity(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> LL Facilitys Phone: <br /> 17c.Signature of Alternate FacifAy(or Generator) Month Day Year <br /> a <br /> Z <br /> W <br /> 18.Designated Facility Ovmer or Operator.Cerblication of receipt of materials covered by the manifest except as noted in Item 17a <br /> °rintedrryped Name (• Signature MorM Day Year <br /> 169-BLS-C 5 11979(Rev.9109) DESIGNATED FACILITY'S COPY <br />