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NON-HAZARDOUS 1.Generator ID Number 2_Page 1 of a Emergency Response Phone 4.Waste Tracking Number <br /> WASTE MANIFEST NOT r%PPLICABLE ' 3792 <br /> 5.Generator's Name and Mit"AdOtess Generalors Site Address(d different Gran mailing address) <br /> r r <br /> Generators Phone: <br /> 6.Transporter t Company Name /� '!� U.S-EPA IDNumber <br /> NOT APPLICABLE <br /> 7.Transporter 2 Company Name US.EPA ID Number <br /> NOT APPLICABLE <br /> B.Designated Facility Name and Site Address US.EPA ID Nunbar <br /> RECOLOGY HAY ROAD NOT APPLICABI-F <br /> 6426 HAY ROAD -VACAVILLE, CA 9W87 <br /> Fa 's Phone: 7 <br /> 10.Containers 11,Total 12-Una <br /> 9,Waste Shipping Name and DescriVdon <br /> No, Type Quantity WUVoL <br /> L I, <br /> 2 <br /> W <br /> Z 2. <br /> � I <br /> 3 <br /> MAIR 0 3 1015 <br /> 4. <br /> i - <br /> 13.Special Handling Instructions and Additional Information <br /> L "y - <br /> y7S-1 <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 all respells in proper condition for transport according to applicable international and national governmental regulations. <br /> Generators/OfferoesPrinted/Typed Name (R� Signature !fI 1 . Month Day Year <br /> F 15.International Shipmetts <br /> t ❑Import to U.S. ❑Export from U.S. Port of entry/exit: <br /> Z Transporter Signature for exports only): Dale leaving U.S.: <br /> ¢ 16.Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 PrintedrTyped Name ! Signature / Month Day Year ` <br /> QTransporter 2 Pdnted/Fyped Name Signature Month Day Year <br /> 17.Discrepancy <br /> 17a.Discrepancy Indication Space <br /> ❑Quantity ❑Type El Residue ❑Partial Rejection El Full Rejection <br /> Manifest Reference Number. <br /> 17b.Allemate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> aLL Facility's Phone: <br /> 17c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> z <br /> N <br /> W I <br /> O f <br /> 18.Designated Facility Owner or Operator.Certification of receipt of maleiials covered by the manifest except as noted in Item 17a <br /> t <br /> Printed/Typed Name Signature �' Month Day Year <br /> f P <br /> 169-BLS-05 11979(Rev.9/09) DESIGNATED FACILITY'S COPY <br /> i <br />