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r <br /> NON-HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Waste Tracking Number <br /> WASTE MANIFEST NOT APPLICABLE I I 1 1 153816 <br /> 5.Generators Name and Mailing Address Generator's Site Address 0 different than mailing address) <br /> yG 2 fit .� R� Sfo _�r0 r• GFr �SZ-!� �j� <br /> Generaloye Fhm: elf- <br /> 6. <br /> 1166.Transporter 1 Company Name .� 1 U.S.EPA V Number <br /> ✓l,iF�_c.�rtr "1/!/ ;�dr �.�C_ NOT APPUCABLE <br /> 7.Transporter 2 Company Name rU U.S.EPA ID Nrnbet <br /> NOT APPLICABLE I <br /> e.Designated Facility Name and Site Address U.S.EPA ID Number <br /> :-',EGOLOGY HAY ROAD NOT A.PPUCABLE <br /> ,,4713 HAY ROAD -VACAVD LE, CA 968$7 <br /> Facili 's Phone: <br /> 1 D.Containers 11,Total 12.Unt <br /> 9.Waste Shipping Name and Oesalplon <br /> No. Type Ouarrtiy WINoI. <br /> 1. <br /> 2 <br /> W b7 <br /> i ur 2. <br /> c� <br /> 3 <br /> 4. I <br /> i <br /> 13.Special Handling Inshrdfons and Additional Information <br /> 14.GEI4ERATOR'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 IabeledJplacarded,and are in all respects in proper condition for transport aecorrfing to applicable international and national governmental regulations. <br /> Generatofs/ONeror's Printad/Typed Name Signature f/) �' Monlh Day Year <br /> j 15.International Shipments <br /> I'- i ❑Import uo U.S. ❑Export from U.S. Port of entry/exit <br /> Transporter Signature for exports on): Date leaving U.S.: <br /> r¢ 16.Transporter Acknowledgment of Receipt of Materials <br /> Materials <br /> 1 Printed/Typed Name t /! Signature Month Day Year <br /> U) <br /> Transporler 2 PrintedrTyped Name Signature — Month Day Year <br /> 17.Discrepancy — <br /> 173.Discrepancy Indcatien Space <br /> ❑Quantity ❑Type ❑Residua ❑Partial Rejection ❑Full Rejection <br /> MarNlest Reference Number. <br /> 17b.Al ernate Facility(or Generator) U-S.EPA ID Number <br /> 04 Facility's Phone: <br /> ® 17c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Lu <br /> I C <br /> 18.Designated Facility Owner or Operator Certification of receipt of materials covered by the manifest except as noted in Item 17a <br /> yped Name Signature Month <br /> A <br /> 169-BLS-CS 11979(Rev.9109) DESIGNATED FACILITY'S COPY <br />