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NON-HAZARDOUS 1.Generator ID Number 2 Page 1 of3.Emergency Response Phone 4.Waste Tracking Number <br /> WASTE MANIFEST NOT APPLICABLE +_ ;`,8 00 <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) ' <br /> CAIO 3A-100t/ ��3 i E . fir,✓; os�_ r <br /> z Dta<,b• P,�, 541-wvrr.k Jb, c-Cv 41}z is f <br /> '2 o3q-"- <br /> cenerafnrr;Phote: y - �l YB- <br /> 6.Transporter 1 Company Name � t U.S.EPA ID Number I <br /> !/nA A. Aj NOT APPLICABLE <br /> 7 Transporter 2 Company Name U.S.EPA ID Number <br /> N iw APPLICABLE <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> I <br /> RECOL.OGY HAY ROAD NOT APPLICABLE <br /> 5,326 HAY ROAD-JACAVILLE, CA 96687 <br /> Fadi sPhone: (70716784718I I <br /> 9.Waste Stripping Name and Description 10.Containers 11.Total 12.Unit <br /> No. Type Quantity WtNol. <br /> O - <br /> i W , <br /> Z 2 <br /> w <br /> r. <br /> 3 � ' I <br /> NY t <br /> 4, <br /> .. twao <br /> r1r- r^rte"�Ir� <br /> 13.Special Harding Instructions and AddillmalInformation <br /> e. <br /> �9S000 y <br /> 14.GENE RATOR'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 labeled/placarded,and are in all respects in proper condition for transport according to applicable International and national governmental regulations. If <br /> Generalor's/0fferor's PrintedrTyll Name Signature a Month Day Year i <br /> ri 15.Intemational Shipments <br /> ❑Importio U.S. ❑Export from U.S. Port of entry/exit: <br /> Transporter Signature(far exports only) Date leavi U.S.: <br /> ¢ 16.Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 Printed Typed Name Signature / Month Day Year_ <br /> z Transporter 2 Prinledirryped Name Month Day Year <br /> 17.Discrepancy <br /> 17a.Discrepancy Indication Space <br /> ❑Quantity `❑Type El Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number. <br /> 1 1 Th.Attemale Facility(or Generator) U.S.EPA ID Number <br /> J <br /> LL Facikty's Phone: <br /> in <br /> W 17c.Signature of Allernale Facile/(or Generator) Month Day Year , <br /> R I <br /> Z <br /> C7 <br /> UlW ' <br /> O <br /> i <br /> LFLPnn-tedrTyped <br /> signated Facilry Owner or OperatorCertification of receipt of materials covered by the manifest except as noted In Item 17a <br /> Name / / }, Signature Month, Day,` /Year <br /> 169-BLS-C 5 11979(Rev.9/09) DESIGNATED FACILfTY'S COPY <br />