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Month Day Year -M <br />9 -BLS -C 5 11979 (Rev. 9/09) TRANSPORTER #1 <br />NON -HAZARDOUS 1. Generator ID Number <br />NON-HAZARDOUS <br />2. Page I—of 3. Emergency —Response Phone <br />Response 4. Waste Tracking Number <br />A E <br />WASTE <br />WASTE MANIFEST A R - <br />�p <br />�07 - 36/- �� -73 <br />7 77 <br />5. Name and Mailing Address Generator's Site Address (if differerlt than mailing addrpss)-, <br />(,75 54 <br />S4 I ctA <br />Generators Phone: <br />cj,. <br />6. Transporter j7Company Name <br />U.S. EPA ID Number <br />Na T <br />7 T n <br />na b te <br />7. Transporter 2 Corn- by Nami <br />sp Corn <br />U.S. EPA ID Number <br />es a <br />8 Designated <br />ed <br />8. Designated Facility Name and Site Address <br />ty N' <br />g Facility <br />U.S. EPA ID Number <br />NOT APPLICABLE <br />.VY ROAD - VACAVILLE, CA 9568-7 <br />Facilit 's Phone: 679-A <br />F c�it s P '70r .7183 <br />Pah Phone: <br />9. Waste Shipping Name and Description <br />10. Containers <br />11. Total <br />12 Unit <br />No. <br />Type <br />Quantity <br />Wt vol. <br />0 <br />p/0 <br />wvc; <br />UZ <br />2. <br />0 <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 Printed/Typed Name, <br />J <br />Signature Month <br />%Daly <br />7 <br />-j 15. International ShipmentsImport to U.S. <br />❑ Export from U.S. Port <br />Z <br />of entry/exit: <br />Transporter Si nature for exports only): <br />Date 1pavinn U.S.: <br />oc 16. Transporter Acknowledgment of Receipt of Materials <br />uJ <br />l'- Transporter 1 PhntedkTyped Name <br />Signature a Month Day Y <br />0 <br />z Transporter 2Pdntbd/Typed Name' <br />Signature Month Day Year <br />17. Discrepancy <br />17a. Discrepancy Indication Space ❑ Quantity ❑ Type <br />El Residue ElPartial Rejection El Full Rejection <br />Manifest Reference Number: <br />17b. Alternate Facility (or Generator) <br />U.S. EPA ID Number <br />L Facility's Phone: <br />17c. Signature of Alternate Facility (or Generator) <br />Month Day Year <br />-- 18. Designated Facility Owner or Operator: Certification of receipt of materials covered by the manifest except as noted in Item 17a <br />Month Day Year -M <br />9 -BLS -C 5 11979 (Rev. 9/09) TRANSPORTER #1 <br />