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ryry)) <br /> NON-HAZARDOUS 1 Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Waste Tracking Number I <br /> WASTE MANIFEST NCY1 APPLICABLES r-;S 93 'II! <br /> 5.Generator's Name and Marling Address Generator's Site Address(if different than mails g address) L <br /> Generators Phone: 1 <br /> 6.Transporter 1 Company Name ! U.S.EPA ID Number <br /> .� �•�, � . �L�(tin•�\K- �YU C�-�''�' j�•� - <br /> 7.Transporter 2 ComNOT APPLICABLE <br /> Company Name U.S.EPA ID Number <br /> NOT APPLICABLE <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number ) <br /> RECOLOGY HAY ROAD NOT APPLICABLE <br /> '426 HAY ROAD- VACAVILI.E.CA 86W? <br /> Facilif s Phone: (7071%37&4718 <br /> 9.Waste Slipping Name and Description NO. <br /> Containers 11.Total 12.Unit <br /> No. Type Quantity WtNol. <br /> 1 <br /> 0 / <br /> W -- <br /> 07 <br /> W <br /> 0 <br /> 3 <br /> 4. <br /> .MAR 0 3 2C1 a <br /> i <br /> 13.Special Handing Instnxtions an dl Additional Information - r q,- — +t 7- <br /> 3 <br /> 14.GENERATOR'S/OFFEROR'S CERTIFICATION:I hereby declare that the contents of this consignment are linty and accurately described above by the proper shipping name,and are classed,packaged, <br /> marked and labeledlplacarded,and are in all respects in proper condition Ior transport according to applicable intemational and national govemmental regulations. <br /> Generators/Offerors Printed/Typed Name Signature -- r:l Month Day Year <br /> + C7% ,2 i <br /> 15.Intemational Shipments <br /> ❑Impart to U.S. ❑Export from U.S. Pore of entryfexit <br /> -Transporter Signature .for experts only): /Date leaving U.S.: <br /> m16.Transporter Adorowtedgment of Receipt of Materials <br /> Transporter 1 Pdnledlfyped Name Signature Mordh Day Year <br /> a L. IY I I 1 r- <br /> Q¢ Transporter 2 Pinted/Typed Name Signature Month Day Year <br /> F <br /> 17.Discrepancy <br /> 17a.Discrepancy Indication Space <br /> ❑Quantity ❑Type El Residue ❑Partial Rejection Full Rejection <br /> Manifest Reference Number. <br /> ? 17b.Allemale Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> u. Facility's Phona: <br /> 17c.Signature of Alternate Facility(or Generator) Month Day Year <br /> a <br /> z <br /> 0 <br /> 0 <br /> W <br /> 18.Designated Facility Owner or Operator.Certification of receipt of materials covered by the manifest except as noted in Item 17a <br /> Prnted/fyped Name ) Signature f MoNh Day Year <br /> 169 BLS C 5 11979(Rev.9/09) `Y V` DESIGNATED FACILITY'S COPY <br />