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NON HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Waste Tracking Number <br /> . <br /> � J i At'PLICABLE 15 <br /> WASTE MANIFEST R,.) j: <br /> 5.Generator's Name and MaAirrp Addtass f Generators Site Address(f different than mailing address) I <br /> O <br /> A. 'ri a ri S T i )(? /Cj '! 64/lll✓I(JOSc� 5�. i. <br /> Act-,h M- 5fac.k-�rh & A "i �_.ts 54 2a <br /> Generators Phone. ✓1 <br /> 6.Transporter 1 Company Name f U.S.EPA ID Number I <br /> NOT APPI-10ABLE <br /> 7.Transporter 2 Company Name U.S.FPA ID Number <br /> NOT APPLICABLE � <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> RECOLOGY HAY ROAD FJOi APPLICABLE I <br /> 5426 HAY ROAD -VACAVILLE, GA 9W I <br /> FaciTrWs Phone: ( 7167 71 a1 <br /> 10.Containers 11.Total 12.Unit <br /> 9.Waste Shipping Name and Description } <br /> No. Type Quantity Wt./Vol. <br /> Ix <br /> W <br /> W <br /> Z 2.UA <br /> ,. <br /> j <br /> 3. 1 <br /> 3 2015 j <br /> 4. l <br /> ENV RONMEKAI <br /> 13.Special Handling kstnrdions and Additional Information <br /> I <br /> I <br /> �i3 9oYyj ' <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 labeled1placarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations. <br /> Generatoes/Offeroes Pdntedflyped Name Signature ` ` r Month Day Year <br /> r - <br /> 1 15.Inleational Ship is <br /> Fz. m �i `❑Import to U.S. ❑Export from U.S. Port of entry/exA: I <br /> Transporter Signature for exports only): Dale leaving U.S.: <br /> cc 16.Transporter Acknowledgment of Receipt of MaterialsUu <br /> j <br /> Transporle 1 Prinfed(ryped Name t;: Signature �' / �) Month Day Year <br /> t-v/ r <br /> aTransporter 2 Prinledfryped Name Slgrlalure Month Day Year <br /> rY � <br /> F <br /> 17.Discrepancy <br /> 17a.Discrepancy Indication Space ❑❑ T ❑ ❑Peal Re Quantity Type Residue Rejection Fua Rejection <br /> Manifest Relerence Number: <br /> 17b.Alternate Facility,(or Generator) U.S.EPA ID Number <br /> J <br /> U � <br /> LL Facikty's Phone: i <br /> w 17c.Signature of Allernate Facility(or Generator) Month Day Year <br /> Q <br /> z <br /> C2 <br /> rn <br /> W ' <br /> I D <br /> 18.Designaled Facility Owner or Operator.Certification of receipt of materials covered by the manifest except as noted in Ilem 17a <br /> Printed7ryped Name Signature �, Mopth Day Year <br /> l ` Y <br /> 1 <br /> 169-BLS-C 5 11979(Rev.9/09) DESIGNATED FACILITY'S COPY <br />