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NON-HAZARDOUS 1.Generates ID Number 2.Page 1 of 3.Emergency Response Phone 4.Waste Tracking Nrmmbw I <br /> WASTE MANIFEST j` U t M-;PUCABLE 1.53787 <br /> S.Generators Name and Mailing Address Generator's Site Address(if different than mailing address) I <br /> �,,� -1.�Uv, '� �U tea, tn:A l o -✓/�°tr_l��'f � , � '���J( G•• vvt+,� r t�%a S c=am /2aS7 <br /> /� // i C.ZA <br /> Ge er �1 <br /> ratoes Phone: '2 G' i!' 7CI(, V' <br /> 6.Transporter 1 Company Name � 1 U.S.EPA ID Number <br /> \f r►h Iq,4. �l� ��UC,�-� VUe— NOT A'PP'LICABLE <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> NOT AP'P'LICABLE <br /> 8.Designated FacRity Name and Site Address U.S.EPA ID Number <br /> RECOI_OGY HAY ROAD NOT APPLICABLE <br /> - " 1 1A;ROAD - VACAVILLE, CA 96W7 i <br /> Facil h's Phone: 7071 f17R471 <br /> 9.WasteShipptrtg Name and Description 10.Costa ners 11.Total 12.Unit <br /> No. Type Quantity WINol. <br /> 1. <br /> Ix - � . <br /> G . ' <br /> W % ! <br /> Z 2. <br /> w <br /> 3. l <br /> MAR U 3 2015 <br /> ENVIRO <br /> t{C'AITL!n +r+•�-•- - <br /> 13.Special Handling Instructions and Additional Information <br /> I <br /> 14.GENERATOR'S/OFFEROR'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 al respects in propercondition for transport according to applicable intemational and national govcmmental regulabons. <br /> GeneratorsMeror's Prnted/Type�Nafge Signature ��; t� Month Day Year <br /> 'Ale h[l /S <br /> £ 15.International Shipm s <br /> 11 Import b U.S. ❑Export horn U.S. Port of entry'exit <br /> 6. <br /> Transporter Signature for exports cnl : bate leaving U.S.: <br /> ¢ 16.Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 Printed/Typed Name Signature Month Day Year I <br /> a til a- � 1 <br /> Transporter 2 Printed/Typed Name Signature 1 Month V= <br /> Day Year <br /> ¢ <br /> 17.Discrepancy <br /> 17a.Discrepancy Indication Space <br /> ❑Quantity 1:1 Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> i <br /> Manifest Reference Number: <br /> 17b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> 7 <br /> U <br /> LL Facility's Phone: <br /> 17c.Signature of Altemate Facility(or Generator) Momh Day Year <br /> Q <br /> Z <br /> (7 <br /> N <br /> w <br /> FP <br /> Designated Facility Owner or Operator.Certification of receipt of melprials covered by the manifest except as noted in Item 17a <br /> ted/Typed Name /f Signature Month Day Year <br /> t <br /> 169-BLS-05 11979(Rev.9/09) DESIGNATED FACILITY'S COPY <br />