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NON-HAZARDOUS 1•Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Waste Trackirfg Number <br /> WASTE MANIFEST l JU 6 APF IAGABLE 153812 <br /> 5. s Name and Marling Address Generators Site Address(d different than mailing address) I <br /> Generators Phew. <br /> 6.Transporter 1 Company Name �. ` U.S.IPA ID Number <br /> /i.t� di p.,. �-r•_ 1�v�1�*,<, ,u _ <br /> NOT APPLICABLE <br /> 7.Transporter 2 Company Name U.S.FPA ID Number <br /> NOT APPLICABLE. <br /> 6.Designated Facility Name and Site Address U.S.EPA ID Number <br /> "OT APPLICABLE <br /> 6-"2S HAY ROAD • VACAVILLE,GA 955 <br /> Fact s Phone• 15- <br /> ta <br /> � 9.Waste Shipping Name and Description 10.Coniners 11.Total 12.Unit <br /> No. Type Quantity WtNol. <br /> ¢ <br /> 1. <br /> O <br /> ix <br /> w _ <br /> z 2 <br /> W <br /> 0 <br /> 3. <br /> 4. <br /> lap", <br /> 13.Special Handing Instructions and Addifional Information1 <br /> le�� tawGam,. <br /> I <br /> 1-4 <br /> 3,:P 6�- <br /> 14.GENERATOR'SIOFFEROR'S CERTIFICATION:I hereby declare the the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and Iabelle#lacafded,and are in al respects in proper condition for transport according to applicable intemational and national govemmental regulations. <br /> Generatoes/OHerors PdntedlTyped Name _ Signature �— ��1 Month Day Year <br /> l ` a <br /> j r .��r '� C.f 1. � .tea <br /> IS.Inlemal oral Shipments i <br /> z ❑Import to U.S. ❑Export from U.S. ort of enhyiexh: <br /> Transporter Signature for exports only): ,Data leaving U.S.: <br /> r¢ 16.Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 PrinteNTyped Name Signature Month Day You <br /> a Transporter 2 Prmrted/Typed Name Signature Month Day Year <br /> t- <br /> 17.Discrepancy I <br /> 17a.Discrepancy Indication Space ❑Pam Re ed.n <br /> E]Orrantity ❑Type ❑Residue j ❑Full Rejection <br /> Manifest Reference Number. <br /> F 17b.Allemate Facility(or Generator) U.S.EPA ID Number <br /> Zi <br /> U <br /> mai. Faciiify's Phone: <br /> 17c.Signature of Altercate Facility(or Generator) Month Day Year <br /> a <br /> z i <br /> w <br /> 0 <br /> 1 S.Designaled Facility Owner or Operator.Cedificalion of receipt of materials covered by the manifest except as noted in Item 17a <br /> P6nled/Typed Name ( Signature / Month Day Y <br /> 169-BLS-C t'11979(Rev.9/09) eJ DESIGNATED FACILITY'S COPY <br />