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NON-HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response one 4.WasMTracldng Number <br /> WASTE MANIFEST ''LICABLE '3814 <br /> 1 <br /> 5.Generator's Name and Mailing Address Generator's Site Address(d dilierent than mailing address) <br /> Z- <br /> Arc - S l�nc 1u�//��kb �� <br /> j Generators Phone: ��� yfJ, 9 G G J*JG r"/c h i%1 <br /> 6.Transporter 1 Company Name U.S.EPA D Number <br /> �'7yyt f�- �Vr�c.t��tc L ��ti G�t=f Y- It1 <br /> _ NOT APPLICABLE <br /> 7.Transporter 2 Company Name w U.S.EPA D Number <br /> NOT APPLICABLE <br /> B.Designated Facility Name and Site Address US.EPA D Nteaber <br /> RECOLOGY HAY ROAD NOT APPLICABLE <br /> `''26 t 1'+Y HOAO "Jf1 ' '-:,AVIU CA Q_&W7 <br /> Fact s Phone: 67947 1 f; <br /> 9.Waste Shipping Name and Description 10.Containers 11.Total 12 Unit <br /> No. Type Quantity WtNol. <br /> w 1 ( T <br /> w <br /> w 2 W 0 v 2013 <br /> c� <br /> ENVIRONMFNIAI <br /> a aP�+ �,1roR�T�I,rnJT <br /> 4. <br /> 13 Special Handling Instructions and Additional Information I <br /> #j 39oa 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 fabeled/plaearded,and we In all respects'n proper condition for transport according to applicable international and national governmental regulations. <br /> Generators/Offeroes Printedrryped Name / Signature 11=1 //�r Month Day Year <br /> J 15.InternationalSftrtents ~ <br /> I— r ❑Impod to U.S. ❑Export from U.S. Fort of entry/exit <br /> z Transporter Signature for exports only): Date leaving U.S.: <br /> cc 16.Transporter Acknmtedgment of Receipt of Materials <br /> Transporter 1 PdntecVTyped Name Signature /' Month Day Year i <br /> z Transporter 2 PrinterYTyped Name Signature Month Day Year <br /> ¢a <br /> ~ 17.Discrepancy <br /> 17a.Discrepancy Indication Space <br /> r ❑Quantity ❑Type El Residue Partial Rejection Full Rejection <br /> _ Manifest Reference Number. <br /> L <br /> 17b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> u Facility's Phone: <br /> w 17c.Signature of Alternate Facility(or Generator) Month Day Year <br /> a <br /> a <br /> Cn <br /> w <br /> a <br /> 18.Designated Facility Owner or Operator:Certification of receipt of materials covered by the manifest except as noted in Item 17a <br /> Prinlecirryped Name %• ,' Signature r Month Day Year <br /> 169-BLS-05 11979( (eV.9/09) DESIGNATED FACILfTY'S COPY <br />