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NON-HAZARDOUS i.Generator ID Number 2.Page 1 of 3.Emergency Response one 4.Waste Tracking Number <br /> WASTE MANIFEST NOT APPLICABLE J-53789 <br /> j <br /> 5.Generators Name and Mailing Address Generator's Site Address(I different than mailing address) t <br /> /lam--lam <br /> Generators Phone: 01— II/0— 39(G - <br /> 6.Transporter 1 Company Name f U.S.EPA ID Number <br /> illelf-1, A. �1� l;c _ �� _ NOT APPLICABLE <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> NOT APPLICABLE <br /> B.Designated Facility Name and Site Address U.S.EPA ID Number <br /> RECOLGGY HAY ROAD <br /> NOTAPPLICABLE <br /> HAY ROAD- VACAVILLE,CA 9W7 <br /> Fad' sPhone: TTR <br /> 9.Waste Shipping Name and Description 10.Containers 11.Total 12.Unit <br /> No. Type Quantity WtNol. <br /> 1. <br /> w 2. j <br /> L r <br /> 3. <br /> MAR 0 3 2015 <br /> 4 m t. <br /> i <br /> 13.Special Handling Instructions and Additional Information <br /> 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 Iaboled/placarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations. <br /> Generaloes(Olfer&s PrinledlTyped Name Signature Month Day Year <br /> J 15.International Shi encs <br /> I= ❑Import to U.S. ❑Export from U.S. Port of entrylexit: <br /> Transporter Signature for exports only): Date leaving U.S.: <br /> is 16.Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 Printed/Typed NameSignature Me" Day Year <br /> ox <br /> rn <br /> Transporter 2 Printed/Typed Name Sign)ynA Month Day Year <br /> 17.Discrepancy <br /> 17a.Discrepancy Indication Space <br /> ❑Ouanttty El Type ❑Residue El Partial Rejection E]Full Rejection <br /> Manifest Reference Number <br /> 17b.Allemale Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> LL Facility's Phone: <br /> 17c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> 2 <br /> C7 <br /> y <br /> W <br /> D <br /> 1 B.Designated Facility Owner Or Operator.Certification of receipt of materials covered by the manifest except as noted in Item 17a <br /> PfinledTypedName Signature i l��' Month Dayy Year <br /> 169-BLS-C 5 11979(Rev.9109) DESIGNATED FACILITY'S COPY <br />