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NON-HAZARDOUS 1 .Generator ID Number 2.Page 1 of 3.Bnergency Response one 4.Waste Tracking Number ' <br /> WASTE MANIFEST NOT APPLICABLE ;,r3799 <br /> 5.Gene or's Name and Mailing Address Generator's Site Address(it different than marling address) - <br /> 1rv��-S Poo elti(O ��lOc'� �rt 1>l �- fsT�.-.�,ros�1. J2�. <br /> 7, Al,ir. VIL . 1I'raI-J40- e- <br /> Generators Phone: -2t-)J- 1-'10 - -39(--/-- <br /> 6. <br /> 39(--G 6.Transporter 1 Company Name _ 1 r U.S.EPA ID Number <br /> '%.'y(1 A. i.. FGt' j _f'I`� kc-, NOT APPLICABLE <br /> 7.Transporter 2 Company Name / U.S.EPA ID Number <br /> N`.0 i APPLICABLE <br /> 8.Designated Facility Name and Site Address US.EPA ID7. <br /> Number <br /> I <br /> RECOLOGY HAY ROAD 1,4011"APPI]CAB <br /> 6126 f1AY ROAD - VACAVIL LE,CA 95687 <br /> Fa s Phone: 7 7 19 <br /> 9.Waste Shipping Name and Description 10.Containers 11.Total 12.Unit <br /> No. Type Quantity WI-Not. <br /> i 1 <br /> a ' <br /> W <br /> Lu z. <br /> c� I <br /> 3 <br /> 20321 <br /> i <br /> 4. <br /> ENVIRONME <br /> 13.Special Handling Insductions and Additional Information <br /> ,Ce <br /> 14.GENERATOR'SIOFFEROR'S CERTIFICATION:I hereby declare that the contents of thls 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 international and national governmental regulations. <br /> GeneralofslOfterces Pdnledrfyped Name Signature ' -' s-T Month Day Year <br /> r i', <br /> -r 15.International Shipments ` <br /> Fz- ❑Import to U.S. ❑Export from U.S. Port of entry/exit <br /> Transporter Signature for exports only): +Date leaving U.S.: <br /> cc 16.Transporter Acknowledgment of Receipt of Materials <br /> W Transporter 1 PdntedlTyped Name Signature _ Month Day Year <br /> z Transporter 2 Pdnterllryped Name Signature Month Day Year <br /> 17.Discrepancy <br /> 17a.Discrepancy Indication Space <br /> ❑Quantity 1:1 Type El Residue ❑Partial Rejection Full Rejection <br /> i <br /> Manifest Reference Number. <br /> r 17b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> CJ � <br /> U <br /> LL. Facility's Phone: <br /> 17c.Signature of Alternate Facility(or Generator) Month Day Year <br /> a <br /> c7 <br /> w <br /> 0 <br /> I <br /> 18.Designated Facility Omer or Operator:Certificallopof receipt of materials covered by the manifest except as noted in Item 17a <br /> Printedrryped Nprn¢` Siggature Month Day-., Year <br /> 169-BLS-CS 1 979(Rev.9/09) DESIGNATED FACILITY'S COPY <br />