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M 0 cccc Lu z w a NON -HAZARDOUS 1. Generator ID Number WASTE MANIFEST �:. "_ iit-£'Li%.+rS 5. Generator's Name and Mailing Address., --.._.-._. I, " • I - • 6. Transporter 1 Company Name ^ 7. Transporter 2 Company Name 8. Designated Facility Name and Site Address LO GY i t 'Y* RGA U a 4269Ay ROAD - VACAVILLE, (,-;A. 95 Farilitv'c Ph-- / n 71 97""Y-1 a 2. Page 1 of 3. Emergency Response Phone 4. Waste Tracking Number _. .. fib Generator's She Address (if different than mailing address) . ,� �+��J �✓ill '. 'i 'i: � � '�. �? �f'�, C 1 U.S. EPA ID Number AJ A-A"HAABLE U.S. EPA ID Number "1" CASLE U.S. EPA ID Number K) T APPLICABLE 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 marked and labeled/placarded, and are in all respects in proper condition for transport according to applicable international and nptional governmental regulations. GeneratoesrOfferoes Printed/Typed Name Signature .. ) Month Day 15. International Shipments ❑ Import to U.S. ❑ Export from U.S. Port of entry/exit: z Trans rter Si nature for ex orfs onl Date leavin U.S.: r 16. Transporter Acknowledgment of Receipt of Materials Transporter 1 Printed/Typed Name_ f Signature Month Day Ir ii .. i ,C- i7 :i`l 1/V"` _ _:moi^ :'i 7 /�". / �; •?4�_... _ :{ % t Transporter 2 Pnrlted/Typed Name \ Signature Month Day '7 /_1 1 Year 'a Year 17. Discrepancy 17a. Discrepancy Indication Space ❑ Quantity ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection Manifest Reference Number: 17b. Alternate Facility (or Generator) U.S. EPA ID Number i Facility's Phone: 17c. Signature of Alternate Facility (or Generator) Month Day Year 18. Designated Facility Owner or Operator: Certification of receipt of materials covered by the manifest except as noted in Item 17a Printed/Typed Name Signature Month Day Year I -BLS -C 5 11979 (Rev. 9/09) TRANSPORTER #1 Shipping Name and Description 10. Containers 11. Total Quantity 12. Unit Wt.Nol. No. Type T9.ste o 6, �_�, :�p rJ� ! .� c e ol1,'4; :�' 2. 3. 13. Snarial 4. Handlinn Inetn,rti—, ani eaalN—i b.t........_ 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 marked and labeled/placarded, and are in all respects in proper condition for transport according to applicable international and nptional governmental regulations. GeneratoesrOfferoes Printed/Typed Name Signature .. ) Month Day 15. International Shipments ❑ Import to U.S. ❑ Export from U.S. Port of entry/exit: z Trans rter Si nature for ex orfs onl Date leavin U.S.: r 16. Transporter Acknowledgment of Receipt of Materials Transporter 1 Printed/Typed Name_ f Signature Month Day Ir ii .. i ,C- i7 :i`l 1/V"` _ _:moi^ :'i 7 /�". / �; •?4�_... _ :{ % t Transporter 2 Pnrlted/Typed Name \ Signature Month Day '7 /_1 1 Year 'a Year 17. Discrepancy 17a. Discrepancy Indication Space ❑ Quantity ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection Manifest Reference Number: 17b. Alternate Facility (or Generator) U.S. EPA ID Number i Facility's Phone: 17c. Signature of Alternate Facility (or Generator) Month Day Year 18. Designated Facility Owner or Operator: Certification of receipt of materials covered by the manifest except as noted in Item 17a Printed/Typed Name Signature Month Day Year I -BLS -C 5 11979 (Rev. 9/09) TRANSPORTER #1