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AkMMI <br /> NON-HAZARDOUS 1.Generator ID Nmtber 2.Page 1 of 3.Emergency Response Phone 4.Waste Traddng Number Q <br /> j WASTE MANIFEST PLOTAPFUCAHLE _' 5 3809 <br /> 5.Generators Name and Mailing Address / Generator's Site Address(d different linen mailing address) <br /> 64 rru*, S rat, JrA/0 3p,)00 7 29.J ' C- 414,r"r/1V 5e, "9" • <br /> H {}4,01 (jam!- -5-6(.� r « 157- 1;- 7 <br /> Ge�r>a Phone: 'nj - S 3 <br /> 6.Transporter 1 Company Name / J U.S.EPA ID Number <br /> f/VI / JVi/rt+�.��h' �1�f/� �I (t L NOT APPLICABLE <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> NOT APPUCABLE <br /> B.Designated Fatuity Name and Site Address U.S.EPA ID Nwdw <br /> RECOLOGY HAY ROAD NOT APPiSCABLE <br /> W6 HAY ROAD-VACAV)LU, CA%W7 <br /> Faali s Phone: (7 07)6764718 i <br /> 10.Containers 11.Total 12.Unit <br /> 9.Waste Shipping Name and Descx rtion No. Type Quantity WtNol. <br /> 1 <br /> l <br /> cc <br /> W <br /> z 2. <br /> W <br /> MAR 0 3 201S <br /> 3. <br /> ENVIRONMENTA,) <br /> 4. <br /> 13.Special Handling Instructions and Additional Information <br /> !i et <br /> #i3 03oG <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 proper condition for transport according to applicable intemational and national governmental regulations. <br /> Generatoes/OfferoesPrtnled/TypedName Signature -f -;? Month Day Year <br /> - ,� .Z /s <br /> 15.Inlemationzl ShiprIienls ❑Import to U.S. ❑Export from U.S. Port.of antryle)k. <br /> Transporter Signature' for exports only): Data leaving U.S <br /> m 16.Transporter Acknowledgment of Receipt of Materials <br /> LU <br /> Transporter 1 Printe yped Name Signature ` y // Monde Day Year <br /> a <br /> Transporter 2 PrintedITyped Name Signature Month Day Year <br /> 17.Discrepancy <br /> 17a.Discrepancy Indication Space ❑ ❑Full Re'Quan' ❑Typo El El Rejection lection � <br /> I <br /> t <br /> Manifest Reference Number. <br /> T 17b.Ahemate Facility(or Generator) U.S.EPA ID Number <br /> J i <br /> U <br /> a Facility's Phone: <br /> 17c.Signature of Allemale Facility(or Generator) Month Day Year <br /> Z <br /> 1 B.Designated Facility Owner or Operator.Certification of receipt of materials covered by the manifest except as noted in Item 17a <br /> PhnlediTyped Name Signature <br /> �Y',/'A t , � � 1A <br /> 169-BLS-C 5 11979(Rev.9/09) DESIGNATED FACILITY'S COPY <br />