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NON-HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Waste Tracking Number I` <br /> ii WASTE MANIFEST NO f APPLICABLE 'J '-43796;. <br /> 5.Generators Name and MaTng Address Generators Site Address(if different than mailing address) 1 <br /> L.►.- (rte, ��✓✓ v 3Aroc`( `! 3( E. 2,f ;fl <br /> Ay c .Q• �T L k �.. cid 9.5 z.l S <br /> ) Generafors Phene: <br /> 6.Transporter 1 Company Name ' ( 1 U.S-EPA ID Number <br /> 11,', A, A, .� ����� - �otic . NOTHPPUCAB j <br /> 7.Transporter Comparry Name U.S.EPA ID Number ! <br /> NOT APPLICABLE <br /> 8.Designated Facility Name and She Address U.S.EPA ID Number <br /> REGOLOGY HAY ROAD NOT APPLICA13LE <br /> HAY ROAD-VACAVILLE,CA 95WI <br /> Facir s Phone: (70716784718 <br /> 10.Containers 11.Total I Z Unit <br /> 9.Waste Shipping Name and Description <br /> No. Type Quantity WtNol. <br /> w 2. <br /> 3. <br /> MAR03L.;:.1 <br /> d Li 4VIRONME,IV. <br /> 13.Special Hauift Instructions and Additional Irdorm kin, <br /> �yi <br /> ' /3 51 s <br /> 14.GENERATOR'SIOFFFROR'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 resprxis inproper condition for transport according to applicable intcmational and national governmental regulataDns. <br /> Generators/Olferor's PP�mtediTyped Name tt Signature f•� h �'; Month Day Year <br /> 15.International Shipments <br /> F r ❑Import to U.S. ❑Export Irom U.S. Port of enlrylexiC <br /> Transporter Signature for expods only): Date leavinn U-S.: <br /> ¢ 16.Transporter Acknowledgment of Receipt of Materials <br /> tu <br /> Transporter 1 Printedffyped Name r Signature /�'�y, Month Day Year <br /> a r S ( t <br /> Z Transporter 2 Printedlryped Name Signature Month Day Year <br /> � � I <br /> 17.Discrepancy <br /> 17a.Discrepancy Indication Space <br /> ❑Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejecdcn <br /> I <br /> Manifest Reference Number: <br /> T 17b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J i <br /> U <br /> tai Facility's Phone: <br /> m 17c Signature of Alternate Facility(or Generator) Month Day Year <br /> Z <br /> 0 <br /> I � <br /> W <br /> ! f] <br /> I <br /> 18.Designated Facility Owner or Operator.Certification of receipt of materials covered by the manifest except as noted in)!am 17a <br /> Printed/Typed Name J r� Signature Month Day Y;ear <br /> 169-BLS-C 5 11979(Rev.9109) DESIGNATED FACILITY'S COPY <br />