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r <br />k NON -HAZARDOUS 1. Generator ID Number 2. Page1 of 3. Emergency Response Phone, 4. Waste Tracking Number <br />H <br />WASTE AN <br />WASTE MANIFEST I <br />I JT APPLICABLE <br />�s <br />5 <br />169 -BLS -C 5 11979 (Rev. 9/09) TRANSPORTER #1 <br />NON-HAZARDOUS <br />Name and Mailing Address <br />Generator's Site Address (if different than mailing address) <br />T" <br />Generator's Phone: <br />6. Transporter 1 Company Name <br />U.S. EPA ID Number <br />00 4 -IA <br />NOT APPLICABUF <br />7. Transporter 2 Company Name <br />U.S. EPA ID Number <br />�i4� UE <br />8. Designated Facility Name and Site Address <br />U.S. EPA ID Number <br />RECOLOGY HAY ROAD <br />.....LICABLE <br />6426 HAY ROAD - VACAVILLE, CA 95W7 <br />F I Is Phone: <br />cil 1701771 <br />—7) 67&4718 <br />9. Waste Shipping Name and Description <br />10. Containers <br />11. Total <br />12. Unit <br />No. <br />Type <br />Quantity <br />Wt.Nol. <br />0 <br />1. <br />a: <br />LU <br />Z <br />2. <br />3.- <br />4. <br />13. Special Handling Instructions and Additional Information <br />14. GENERATOR'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 labeled/placarded, and are in all respects in proper condition for transport according to applicable international and national governmental regulations. <br />Generator's/Offeror's PrintecIfTyped Name <br />Signature Month Day Year <br />_j <br />15. International Shipments <br />El Import to U.S. <br />❑ Export from U.S. Port <br />z <br />of entry/exit: <br />Transporter Signature for exports only) <br />Date leaving U.S. <br />='7 <br />cc <br />16. Transporter Acknowledgment of Receipt of Materials <br />r <br />0 <br />Transporter 1 Printed/Typed Name <br />Signature <br />re Month Day Year <br />Z <br />Transporter 2 Printed/Typed Name <br />Signature Month Day Year <br />Discrepancy <br />J17. <br />17a. Discrepancy Indication Space ❑ Quantity ❑Type <br />1:1 Residue El Partial Rejection ❑Full Rejection <br />Manifest Reference Number: <br />171b. Alternate Facility (or Generator) <br />U.S. EPA ID Number <br />u- <br />Facility's Phone: <br />LLj <br />17c. Signature of Alternate Facility (or Generator) <br />Month Day Year <br />F - <br />z <br />a <br />rn <br />18. Designated Facility Owner or Operator: Certification of receipt of materials covered by the manifest except as noted in Item 17a <br />PrintecifTyped Name <br />Signature. Month Day Year <br />169 -BLS -C 5 11979 (Rev. 9/09) TRANSPORTER #1 <br />