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1139-13LS-C 5 11979 (Rev. 9109) TRANSPORTF-H #1 <br />NON-HAZARDOUS <br />I 1. Generator 1D Number <br />2. Page 1 of <br />3. Emergency Response Phone <br />4.. Wavle Trackhlg Number a S <br />'!'i 2 <br />WASTE MANIFEST <br />NOT APPUCABLE <br />1.10 <br />5. Generalor's Name and Mating AddressGenerator's Site Address (d different than g address) <br />6T(t <br />r <br />Generelor's Phone: J <br />u. Transporter 1 Company Name U.S. EPA ID Number <br />NOT APPLICABLE <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />NOT APPLICABLE <br />8. Designated Facility Name and Site Address U.S. EPA ID Number - - <br />RECOLOGY HAYAOAa NOT APPLICABLE <br />6426 HAY ROAD - VACAVILLE, CA 95687 <br />FadlilYs Phone: 7 67&4718 <br />9. Waste SNpON Name End DescripllonOuarf <br />10. Contatrert <br />11. Total <br />dY <br />12. Unit <br />"oI <br />No. <br />Type <br />L �lfiav .. <br />cc <br />VIA' <br />Oafb.A <br />wrSilAR+: - S <br />s4r�� <br />2. <br />'('1Y•5` � <br />� <br />�•���• <br />se x' <br />iYI <br />lei i, <br />ae+�ki <br />. <br />x .� .,ir.•. <br />4. <br />13. Special Handing Instructions and Additional Information _ <br />14. GENERATOR'SlOFFEROR'S CERTIFICATION: I hereby declare that Bile contents of this cons4yrient are fully and acturatey desrnbedabove by the proper shipping name, and are classlfled, peckegedq <br />marked and IabeWplaeardad, and are In all respects Irrpreper condrllon for Onepon axor®ng to spplcable htemational and nellonal governmental regulations. <br />Generalor'sf011emesPdnted/iypedNam ` Signature Month Day -:Year <br />c 7 <br />.4'� <br />.r <br />15. Irtemellonal Shiprents 0 lmpcwl to U.S. ❑ Export from U.S. Part of eNry/e>ot <br />�— <br />Transporter Signature N exioorts only): / Date leaving U.S.: <br />15. Transporter Acknowledgment of Recelpt of Materiels <br />Transporter 1. dnted/Typed Name Signature Month Day <br />CL <br />/Year. <br />C <br />Tran f7 Pdnted!Typed Name Sig rd Month Day Year <br />17. Diacrepancy <br />17a. Discrepancy Indication Space E]Ouanb'y Type ❑ Residue ❑ Partial Re)ecdon ❑ Full Floecllon <br />Manifest Reference Number. <br />17b. Alternate Fadlity (or Generator) U.S. EPA ID Number <br />a <br />s <br />Faclitys Phone: <br />170. S of ARemate Facility (or Generator) Month Day Year <br />(J <br />O <br />P -i - ✓: '}^ F.h t,f . f� M _•Y R� `� f <br />l F �: .Er'•e.1,'�i Y 3 �5 L• �i� �°' �'' 'i�� � 3�. � ;�l" r t'k <br />ff�n � ,+.' , <br />���� �7��'�f�4•-�^��r f�E y�. � P,� � <br />�,c <br />� <br />.� �. .hc� . 2�� itr �� <br />past , f ' <br />ti !• ps?:, yt� 'zA � S � k. uA'u �'J "x P X� '� d° h.d':i,/t?9; ��f ���tAJ. <br />�}y���'T •1:�5 `fit, �,xi�x t'ct 4 '6. -.-i6'K+... <br />��i <br />} .:i»Tye' ,�:,r't? yi,; E�� r.i PT:.�.�,Si.N't:'-i'L',�.- �-.6.� <br />y�T ii`��Y�2'�-�_}f'!.� >"�t�° <br />18. Designated FacRty Owner. or Operator. Certifibation of receipt of materiels covered by the manifest eicept as noted In Item 17 <br />Prue d Nome Month Day Year <br />1139-13LS-C 5 11979 (Rev. 9109) TRANSPORTF-H #1 <br />