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L32� <br /> i <br /> NON-HAZARDOUS I.Generator ID Nu T9w 2.Page 1 of 3.Emergency Response Phone 4.WasteTraddng Number <br /> WASTE MANIFEST NOTAPPLICABl.F: 1.53803 <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if dfferent than mating address) <br /> 6;4 / i'Cc v S ,1�j l.r„`(l �i�:t�:��� A-5 f <br /> f�erreratora Phone: /,!:;,'--A— t^ c <br /> S.Transporter 1 Company Nemo U.S.EPA ID Number <br /> UT APPLICABLE � <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> NOT APPLICABLE <br /> B.Des%nded Facility Name and Site Address U.S.EPA ID Number <br /> RECOLOGY HAY ROAD _ NOT APPLICABLE <br /> 6426 HAY ROAD VACAVILLE, GA } <br /> jacy es Phone: (707167847 1 A <br /> 9.Waste Shipping Name and Description 10.Cantainers 11.Total 12.Unit <br /> MAR 03 20 5 No. Type Quantity W1Nol. <br /> I O 1. <br /> W <br /> z 2. <br /> W <br /> 3. <br /> 4 <br /> 13.Special Handling Instructions and Additional Informationel <br /> i <br /> I l <br /> I <br /> ' - /390 77 i <br /> 14.GENERATOR'S/OFFEROR'S CERTIFICATION:I hereby declare that the contents of this consignment are fulty 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 /> Generatolr's/Offeror's PdnbKgyped Name / Signature a fJ� Month Day Year <br /> ( !� � �� �r a✓�[_"'r` ;.fes: _ Cwt`-. � .2 �S <br /> 15.International Shipments ❑ I <br /> Import to U.S. ❑Export from U.S. Port tN enlrylexit: <br /> Transporter Signature(io(exports only): Da(e leavin U.S.: <br /> ¢ 16.Transporter Acknowledgment of Receipt of Materials <br /> La <br /> ¢ Transporter 1 Printedlryped Name Signature Month Dey Year. <br /> a Transporter 2 Pdnted/fyped Name Signature i Month Day Year <br /> 17.Discrepancy <br /> 17a.Discrepancy Indication Space <br /> ❑Quantity ❑Type ❑Residue ❑Partial Rejection ❑Fu8 Rejection <br /> Manifest Reference Number. <br /> T 17b.Allemate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> a Facility's Phone. <br /> m 17c.Signature of AAemate Facility(or Generator) Month Day Year <br /> F <br /> Z <br /> wW <br /> D <br /> 18,Designated Facility Ovmer or Operator.Cert fication of receipt of materials covered by the manifest except as noted in Item 17a <br /> PrinledTyped Name Signature Month Day Year <br /> 169-BLS-C 5 11979(Rev.9/09) DESIGNATED FACILITY'S COPY <br />