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NON HAZARDOUS 1.GeneralarID Nutlbet 2.Page' of 3 6nergency Response Phone 4.Waste Tracking I <br /> WASTE MANIFEST NOT APPLICABLE 762 f <br /> 5.GeneratooWame and ailing AddrewI !L ,f AU L4 Generaloes Site Address(if dtlerenl than mailing address) <br /> pa L, <br /> Generators Phone: <br /> 6.Transpoder 1 Company Name U.S.EPA ID Number <br /> ,3..11�2t ( 1 cv�}'s !i<" i 1L' NOT APPLICABLE <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> NOT APPLICABLE <br /> i <br /> 8.Designated Facility Name and Site Address US..EEPA ID Number APPLICABLE <br /> RECOLOGY HAY ROAD <br /> ROAD-VACAVILLE.CA 98W <br /> Facilit s Phone: (-707)67"718 1 <br /> 9.Waste Shipping Name and Description ! 10.Containers it.Total 12.Unit <br /> No. Type Quantity WWoI. <br /> 1. <br /> MAR 0 3 2015 <br /> W 2 ENVIHONMENTA <br /> t! R , <br /> 3. <br /> 4. — <br /> 13.Speclal tbloft Instructions and Additional Information <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 propercondillion for transport according to applicable international and national governmental regulations. <br /> Generator'sJ0lferorS Printed/Typed Name Signature Month Day Year <br /> S 15.International Shipmd Import to U.S. ❑Expert from U.S. P#of a"lexit: <br /> �— <br /> Transporter Signature for ex ons only): Ddte leaving U.S.: <br /> m16.Transporter Acknowledgment of Receipt of Materials <br /> Y Year Da <br /> Transporter 1 Printed/typed Name Sigrtehse Month <br /> J <br /> Z Transporter 2 PrintedlFyped Name Signature Month Day Year <br /> I 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 /> a Fadl tys Phone: <br /> Q� 17c.Signature of A!temate Fatty(or Generator) <br /> Month Day Year <br /> Z <br /> to <br /> W <br /> 18.Designated Facility Owner or Operator.Certification of receipt of materials covered by the manrlest except as noted in Item 17a <br /> PdnteVyped Name Signature �Y I <br /> 169-BLS-0 5 11979(Rev.9109) DESIGNATED FACILITY'S COPY <br />