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lCC F a IX LL 2 LL a NONHAZARDOUS 1. Generator ID Number 2. Page 1 of 3. Emergency Response Phone 4. Waste Tracking Number WASTE MANIFEST Jif: `11 5. Generator's Name.and Mailing Address lb Generator's Site Address (if dffferent than mailing address) ��th�y� Generator' s'Phone: ✓• t r 4} 1 6. Transporter 1 CorfSpiiy ame7 ' f r ' }, F? U1.. EPA ID Number 64r—�i iC�4�`BLE 7. Transporter 2 Company Nam ' U.S. EPA ID Number - 8 Designated Facility Name and Site Address U.S. EPA ID Number <34�6 HAY ROAD - V.ACAVILLE, CA 9,W7 Facilitv'c Phnna- (t X37) 673-47i q I 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, Name and Description 10. Containers 11. Total Quantity 12. Unit Wt1Vol. Signature Month No. Type F9.hipping s 15. Iritemational Shipments! - ❑ Import to U.S. ❑ Export from U.S. Port Trans orter 51 nature for ex orts on : of entry/exit: Date leavin U.S.: 2. ' Transporter 1 Printed/Typed Name h a Signature Month r ( I I r Day 3. Transporter P P Name r 1 X Signature Mortlh I Day 13 Snerial 4. Handlinn Inch irfinne end v,i.ce��.,�1 i�r.......,r.,.., 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 la beled/placarded, and are in all respects in proper condition for transport according to applicable international and national governmental regulations. Generator's/Offera-es Printed/Typed Name Signature Month Day 15. Iritemational Shipments! - ❑ Import to U.S. ❑ Export from U.S. Port Trans orter 51 nature for ex orts on : of entry/exit: Date leavin U.S.: 16. Transporter Acknowledgment of Receipt of Materials ' Transporter 1 Printed/Typed Name h a Signature Month r ( I I r Day !9� j'�.. Transporter P P Name r 1 X Signature Mortlh I Day 17. Discrepandy 17a. Discrepancy Indication Space ❑ Quantity ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection Manifest 171b. Alternate Facility (or Generator) Facility's Phone: 17c. Signature of Alternate Facility (or Generator) U.S. EPA ID Number Month Day Year 18. Designated Facility Owner or Operator: Certification of receipt of materials covered by the manifest except as noted in Item 17a PrintedlTyped Name SI natuia / + g Month Day Ye^ars I -BLS -C 5 11979 (Rev. 9/09) TI3AIVSPOFdI 1=R #1