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NON-HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Waste Tracking Number <br /> i WASTE MANIFEST NO 1 AFFUCABLL a L 5 3 8 08 <br /> 77 s Name and Mailing Address Generalor's Site Address(t 0,erent than mailing address) <br /> Generators Phone: ` 7 32 G•6 <br /> 6.Transporter 1 Company Name �/,� / U.S.EPA ID NwrAw <br /> j f NOT APPLICABLE <br /> 7.Transporter 2 Company Name I U.S.EPA IDNwnber <br /> I 1I0T APPLICAME <br /> 8.Designated Facility Name and Site Address US.EPA ID Number 1 <br /> (ECOLOGY HAY ROAD "J0T,-PPI-!CABLE <br /> -.126 HAY ROAD -VACA"LLE,CA 05M <br /> Faa s Phone: / <br /> 9.Waste Shipping Name and Description 10.Containers 11.Total 12 Ung <br /> No. Type Ouantrly Wtivol. <br /> cc <br /> 1. <br /> ¢ <br /> W <br /> W 2- <br /> I <br /> 3. <br /> I <br /> C% <br /> i13.Special Handling Instructions and Additional Informallon <br /> Y <br /> I <br /> 14.GENERATOR'SIDFFEROR'S CERTIFICATION:I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classfied,packaged, <br /> marked and Iabeledlptacarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations. <br /> Generator'slOfierw's Printed/Typed Name Signature r �� Month Day Year <br /> 15.International Sh fnenls / <br /> F- 7 ❑Import to U.S. ❑Export from U.S. P�of entrylexit i <br /> — Transporter Sinaturo forer.ortsonl : Dale leavino U.S.: <br /> w 16.Transporter Acknowledgment of Receipt of Materials <br /> 11 <br /> I' Transp4Aer 1 PrintedrTyped Sl ty <br /> cc / gna Mattia Day Year <br /> Transporter 2 Printedrryped Name Signature / Month Day Year <br /> F <br /> i <br /> 17.Discrepancy <br /> I <br /> 17a.Discrepancy Indication Space ❑ i Quantity ❑Type Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number. <br /> 17b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> v <br /> rai Facility's Phone: <br /> LOU 17c.Signature of Aflemate Facility(or Generator) Month Day Year <br /> H <br /> Z <br /> 0 <br /> En <br /> w <br /> 0 <br /> I <br /> 18.Designated Facifly Owner or Operator Certification of receipt of materials covered by the manifest except as noted in Item 17a <br /> Pdnledlryped Name ��•- 1 SignatureM°`}th Day Yea <br /> I r -- <br /> 169-BLS'-C 5' 11979(Rev.9/09) DESIGNATED FACILITY'S COPY <br /> i �. <br />