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F2Generatoe§ <br />OUS 1, Generator ID Number <br />EST """"APPLICABLE <br />and Mailintg Address, )"r r -c— i Y{ A Tui r" Y'- (r�)t'-i jGA <br />Generators Phone: 76/ <br />6. Transporter 1 Company Name <br />7. Transporter 2 Company Name <br />B. Designated Facility Name and Site Address (•- <br />- 1, , <br />6426 HAY ROAD VACAVILLE, <br />Farilih)'c Phnno (it311 fl—, R A71 R <br />MPageof 3.Emergencysponse PhReone 4. Waste Tracking Number ,.y8 74 <br />Generators Site Address (If different than mailing address) <br />U.S. EPA ID Number <br />U.S. EPA ID Number <br />U.S. EPA ID Number <br />+N1 <br />18. Designated Facility Owner or Operator: Certification of receipt of materials covered by the manifest except as noted in Item 17a <br />Prigte'UTyped Name g Month Day Year <br />tt Si nature / <br />1 -BLS -C 5 11979 (Rev. 9/09) v TRANSPORTER#1 <br />9. Waste Shipping Name and Description �\� <br />10. Containers <br />11. Total <br />12. Unit <br />❑ <br />j <br />Quantity <br />Wt.Nol. <br />No. <br />Type <br />1 <br />elf. 7 S <br />= Transpolier 1 Printed typed Name 1 g <br />j <br />Signature 9 q r <br />„^ J <br />Month <br />Day Year <br />n t j. a9 2 <br />U{ <br />fq1 <br />t <br />' <br />Trans r PnrM'ed(Fyped Name a <br />' 1 Signatur r 1 <br />1 , <br />Month' <br />Day Year <br />1 17. Discrepancy <br />1 <br />2. <br />17a. Discrepancy Indication Space <br />❑ Quantity <br />❑ Type ❑ Residue ❑ Partial Rejection <br />❑ Ful Rejection <br />Manifest Reference Number: <br />3. <br />17b. Alternate Facility (or Generator) <br />U.S. EPA ID Number <br />4. <br />i <br />i <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 />GBnerRtne,JOrfP,n Prinfaritr—M Ah.no <br />18. Designated Facility Owner or Operator: Certification of receipt of materials covered by the manifest except as noted in Item 17a <br />Prigte'UTyped Name g Month Day Year <br />tt Si nature / <br />1 -BLS -C 5 11979 (Rev. 9/09) v TRANSPORTER#1 <br />Month <br />uay Year <br />15. International Shipments <br />F ❑ Import to U.S. <br />❑ <br />Trans rte' Si nature for ex ons onl <br />Export from U.S Port of entry/exit <br />Date leavin U.S.: <br />x 16. Transporter Acknowledgment of Receipt of Materials <br />L <br />= Transpolier 1 Printed typed Name 1 g <br />j <br />Signature 9 q r <br />„^ J <br />Month <br />Day Year <br />n t j. a9 2 <br />U{ <br />fq1 <br />t <br />' <br />Trans r PnrM'ed(Fyped Name a <br />' 1 Signatur r 1 <br />1 , <br />Month' <br />Day Year <br />1 17. Discrepancy <br />17a. Discrepancy Indication Space <br />❑ Quantity <br />❑ Type ❑ Residue ❑ Partial Rejection <br />❑ Ful Rejection <br />Manifest Reference Number: <br />17b. Alternate Facility (or Generator) <br />U.S. EPA ID Number <br />i <br />i <br />Facility's Phone: <br />17c. Signature of Alternate Facility (or Generator) <br />Month <br />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 />Prigte'UTyped Name g Month Day Year <br />tt Si nature / <br />1 -BLS -C 5 11979 (Rev. 9/09) v TRANSPORTER#1 <br />