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1.Generator ID Number 2 Pa e 1 of 3.Emergency Response Phone 4.Waste Tracking Number lu <br /> NONHAZARDOUS 9 9 cl P �{ I <br /> WASTE MANIFEST NOT AP1-1UQ BLE 153"8 1 <br /> i <br /> 5.Generator's Name and Mailing Address Generators Site Address(d different ttlen mailing address) <br /> E A10 3k Ioo� <br /> r^rG� p - q,{gt,.ji Q X14 SLI�j :I 1 <br /> Generator's Phone: �''7 �G <br /> f — ! �O kqe)r CA <br /> 6.Transporter 1 Company Namef r / l�; U.S.EPA ID Number JJ <br /> '_iCABLE <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> i <br /> i NOT APPLICABLE <br /> 8.Designated FadGq Name and Site Address U.S.EPA D Number I. <br /> RECOLOGY HAY RO.A.r.; NOT APPLICABLE <br /> X426 HAY ROAD- 7 C.AVILLE,CA 9%87 <br /> Facie 's Phone; (7071678-4718 <br /> 9.Waste Shipping Name and Description 10.Containers 11.Total 12 Unit <br /> 1 <br /> No. Type Quantity WWol. <br /> cc 1. I <br /> D7 <br /> W L { r <br /> Z 2. <br /> W <br /> i <br /> 1 <br /> 3. <br /> I 1 <br /> 13.Special Handling Instructions and Adctlional Information ` *N r�ar <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 labeled/placarded,and are in all respects it proper condition for transport according to appfirable international and national governmental regulations. <br /> GoneratoestOflaroes Printed/Typed Name Signature / r' Month Day Year <br /> /S <br /> J 15 intemalional Shipments `J Import to U.S. <br /> Po ❑E1w6om U.S. Port of entry/exit <br /> Transporter Siature for exports only): Dal.leavi U.S.: <br /> µ¢¢¢r 16.Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 Printed/ryped Name Signahre Month Day Y <br /> ff <br /> O <br /> C Transporter 2 Printed7yped Name Signature Month Day Year <br /> 17 Discrepancy <br /> 17a.Discrepancy Inliicalion Space ❑ l ❑Full P4.11m Quantity ❑Type ❑Residue Partial Rejection <br /> Manifest Reference Number. <br /> 17b.Allemate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> LL Facility's Phona: <br /> w 17c.Signature of Alternate Facjlihy(or Generator) Month Day Year <br /> a <br /> Z <br /> (7 <br /> rn <br /> W <br /> O <br /> I <br /> 18.Designated Facility Owner or Operator.Certification of receipt of materials covered by the manifest except as noted in Item 17a <br /> PrinlecYTypedName Signature ' ��� Month Day Year <br /> _ f <br /> G�- <br /> 169-BLS-C 5 11979(Rev.9/091 DESIGNATED FACILITY'S COPY <br /> 1 <br />