Laserfiche WebLink
ON-HAZARDOUSTIGe- <br /> NratorID Number 2 Page 1 d 3.Emergency Response Phone 4.Waste Tracking Number <br /> WASTE MANIFESTNOT APPLICABLE 3813 <br /> 5.Generators Name and Malting Address Generators Site Address(if different than maillirig address) <br /> T�.ti✓ =U (u '�;AICai( r�S i1 <br /> L- 13 <br /> i <br /> GeneraWfsPhone: ��' ��Q 3/(,G C✓toL� � <br /> 6.Transporter 1 Company Name U.S.EPA 10 Number <br /> j <br /> NOT APPLICABLE <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> NOT APPUCABLE <br /> 8.Designated Facility Name and Sit-Address U.S.EPA ID Number <br /> RECGLOGY HAY ROAII NOT 4PPUCABLE <br /> X28 RAY ROAD - VAC AVILLE,CA 95687 <br /> Facifit's Phone: (707)6764718 <br /> 10.Containers 11.Total 12.Unit <br /> 9.Waste Shipping NameaW Desdlptlon <br /> No. Type Quantity wwa'./ <br /> 1X 1 1 Y <br /> Lu , <br /> Z 2. <br /> Lu <br /> 3. M❑ 0 3 2015 <br /> 4. ,71m . 1. I11r <br /> 13,Special Handling Instructions and Additional Information <br /> I <br /> Af l <br /> /39o "-3 <br /> i I <br /> 14.GENERATOR'SIOFFEROR'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 Iabeled/placarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations. <br /> Generato/s/Offeroes Prinled/Typed Name Signature Month Day Year <br /> 15.International Shipments <br /> . ❑Import to U.S. ❑Export from U.S. PArt of entrylezil• <br /> Transporter Signature for exports onl to leaving U.S.: <br /> m 16.Transporter Acknowledgment of Receipt of Materials <br /> V Transporter 1 Printed/Typed Name 1 Signature /t f % Month Day Year <br /> cc <br /> P� <br /> rainMonth Da Year <br /> Z Transporter 2 Pdnled/Typcd Name Signature y <br /> 4 <br /> F- <br /> 17.Discrepancy _ <br /> 17a.Discrepancy Indication Space ❑ ❑QuanLly Type Residue ❑Partial Rejection Full Rejection <br /> Manifest Reference Number. <br /> 17b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J I <br /> U <br /> 4LLFacility's Phone: <br /> OL 17c.Signature of Alternate Facility(of Generator) Month Day Year <br /> t- <br /> 4 <br /> z <br /> w <br /> Lu <br /> 0 <br /> 18.Designatod Facility Owner or Operator.Certification of receipt of materials covered by the manifest except as noted in Item 17a <br /> PrintedRypod Name Signature f Mon Day Year <br /> 169-BLS-05 11979(Rev.9/09) DESIGNATED FACILITY'S COPY <br />