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NONHAZARDOUS 1 � N nnlbaf 2.Page 1 of 3.Emergency Response Phone 4.Waste Trocidng Numbw <br /> WASTE MANIFEST NOT APPUCABLE 8 10 <br /> 5.Generator's Name and Mailing Address Generalor's Site Address(d different than mailing address) <br /> CJs 1r/+r 5 /)t?[o d s/ <br /> .Gente ::J Jjam!poga ��3r' t_ s/1/". i r F;O5r�_ ;ice✓ <br /> erator's Phone: 7 U9- Yy�'396�� 'j (.k�[j a• Uq <br /> 8.Transporter 1 Company Name � 11 ! U.S.EPA ID Ntmber A. 111��j� ��� r.F' � t n L. NOT APPLICABLE <br /> I <br /> 7.Transporter 2 Company Name / U.S.EPA ID Number <br /> NOT APPLICABLE i <br /> B.Designated Facility Name and Sb Ad*m US.EPA ID Nriber <br /> RECOLOGY HAY ROAD NOT APPLICABLE <br /> -JAY ROAD-VACAVILLE, CA M87 <br /> Farili s Phone: 678,471 <br /> 10.CormlBhrers 11.Total 12 Unit <br /> 9.Waste Shhft Nanne and Desalpflon <br /> No. Type Quantity WiNol. - <br /> Ix <br /> 0 to <br /> P <br /> C ps 07 <br /> 2. J <br /> M; 1. 0 J L <br /> ,015 <br /> ENVIRONMENIAI <br /> 4. <br /> I <br /> 13.Special Handling Instructions and Additional Information <br /> /3gO373 <br /> 14.GENERATOR'SlOFFEROR'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 labefedrplacarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations. <br /> Generator's/Otfemr's Printecirfyped Nam; Signature i %; Month Day Year <br /> E 15.International Shiprhents <br /> r ❑Import to U.S. ❑Export Imm U.S. Prid of entrylexit: <br /> Transporter Si tura for exports only): Date leavi U.S.: <br /> 16.Transporter Acknowledgment of Receipt of MaterialsLu <br /> _ <br /> Transporter 1 Fr ntedfTyped Name Signature Month Day Year <br /> JE <br /> CL V <br /> Z TransporterPrInted/Typed Name II Signature Mordh Day Year <br /> 1� <br /> 17.Discrepancy <br /> 17a.Discrepancy Indication Space <br /> Quantity Type ❑Residue ❑Partial Rejection Full Rejedion <br /> Manilesl Reference Number. <br /> 17b.Atlemate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> mai Facility's Phone: <br /> G 17c.Signature of Aftemate FacifAy(or Generator) Month Day Year <br /> a <br /> 113.Designated Facility Ovmer or Operator.Certification of receipt of materials covered by the manifest except as noted in Item 17a <br /> Printed/Typed Name Signature Month Day Year <br /> 169-BLS-C 5 11979(Rev.9/09) DESIGNATED FACILITY'S COPY <br />