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�h { <br />169 -BLS -C 5 11979 (Rev. 9/09) TRANSPORTER #1 <br />NON -HAZARDOUS <br />WASTE MANIFEST <br />I I. Generator ID Number <br />NOT APPLICABLE <br />2. Page 1 of 3. Emmosponse Phone <br />`7 <br />4. Waste Tracking Number Y <br />.(d� <br />5. Genera ofs Name and fvlalling Address Generatof Ste Address It dfferent an mailing address) <br />V �� rl;���© �b� 5#�4c�Um <br />t 8ral6r s P ne: 1 <br />6. TransporterCompany <br />Name ° N U.S. EPA ID Number <br />t�OT APPLICABLE <br />7. T nsp rte C ame U.S. FPA ID Number <br />Iy NOT APPLICABLE <br />8. Desi nated Faa1L y Name and Site Address U.S. EPA ID Number <br />RECOLOCY HAY ROAD NOTAPPLICABLE <br />6426 HAY ROAD - VACAVILLE, CN95637 <br />Facie s Phone: 70 67134718 <br />10. Containers <br />9. Waste Shipping Name and Description <br />11. Total <br />12. Unit <br />No. Type <br />Quantity <br />W1Nol. <br />sCr <br />L <br />I/'�➢ 1(;L1 <br />�'Jl <br />(IA11i1 <br />,i M Rte` r,%��,:: <br />WW4 <br />i lit <br />z <br />- x <br />'aE <br />3. <br />c�s'� <br />4. <br />���5 sin ''• <br />13. Special Handing Instructions and Addtlonal Information <br />14. GENERATOR'SfOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consigmterd are idly and accurately described above by the proper shipping name, and are classified, packaged, <br />marked and labeledlplacarded, and are, In all respects In proper condition for transport according to applicable intema6enal and ianai gave regulations. <br />Generator s/Offeror's Pintecl(Typed Name Signature Month Ray � Year <br />\ O <br />15. Intematfonal* hip nts <br />Import to U.S. ❑ Export from U.S. Pod of entry/exit: <br />Transporter Signature (a exports Date leeng U.S.: <br />w <br />16. Transporter Acknowledgment of Receipt of Materials <br />OTran <br />orter 1 Pdnl Name ( �-/ Sign ore i Mach Da Yea <br />r 1�( 1 <br />N <br />a <br />l % <br />Trensp Aer 2 1 yped Name Sig afore Mond Day year <br />F <br />17. Discre <br />17a. Discrepancy Indication Space ❑ Quantity ❑ Type ❑ Residue ❑ Pardal ReJeWon ❑ Full fieledlon <br />Manliest Reference Number. <br />17b. Alternate Facility (or Generator) U.S. EPA ID Number <br />U <br />1¢L. <br />Facility's Phone: F <br />W <br />17c. Signature of Alternate Facility (a Generatol Month Day Year <br />z <br />y <br />�x ,;; ��.�.�' ,,.r7 `,'' cb a: � 1,�4-� ���jR�,(t.�''��yyy, �' � �y ��jt'ry/�y�' r ?�r•�(` k ", ��P` �';. 'a �,. ��:'_qy�' �p�s•�x <br />%`_y'7\"'1k'�r �YS Y` �. -iT� `'. `IF '4Ay5Q3'�'•ct3''.`t7t' `N,. '' l <br />'Iki+ ..4 r o'nfy �' §33�'-,K,,P'._ t <br />.i �. '�1 i <br />c <br />?'n <br />fir, 4k <br />s•�' <br />t`%i t. <br />,i� <br />"- <br />-A <br />18. Designated FadYty Owner or. 0perator. Certification of receipt of materials Wred by the marlifesMeept as noted In 17a <br />11 <br />Namej+r � Modh Day Yea <br />169 -BLS -C 5 11979 (Rev. 9/09) TRANSPORTER #1 <br />