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Q <br />cc <br />W <br />z <br />Lu <br />c5 <br />Y _ } <br />NON -HAZARDOUS 1• Gene rator.DNumber <br />WASTE MANIFEST '' A PPLJGASL.`- <br />Generator's Name ((a�nd Mailing Address n <br />�� dry Lt US T f r - 1 k, VJ t} 13 � e <br />-, -- I-Isf e^; r= � r r 1 Y <br />generator's Phone: -i :Z2 <br />6. Transporter 1 Company Name <br />Transporter 2 Company Name ; <br />1. Designated Facility Name and Site AddressRECOL <br />♦ I 1 <br />5426 HAY ROAD - VACAVILLE, CA 95687 <br />Facili 's Phone: ± 678-4718 <br />9, Waste Shipping Name and Description <br />G r <br />Oou <br />2. <br />3. <br />4. <br />r_1 3. Special Handling tnstructions and Additional Information <br />72.Page 1 0l 3. Emergency Response Phone 4. Waste Tracking Number :./ .• '. -.; <br />1 of 3, Emergency <br />r <br />Generator's Site Aciarmp (rt different than mailing address) <br />5 GCtti 0v-, <br />U.S. EPA ID Number <br />U.S. EPA ID Number <br />��� � ,�•��� Lam., .. . <br />U.S. EPA ID Number <br />10. Containers 11. Total 12. Unit <br />No. Type Quantity Wt.Nol, <br />proper <br />14. GENERATOR'S/OFF RR'Sand are in I herinbpropeacondtton for transport according ding to applicables consignment are linternational ly and accurately <br />nd national governmentalregulations 1pp ng name, and are classified, packaged, <br />marked and labeled/placarded,„ Month Day Year <br />Signature /j <br />Generatoeslofferoes Printed/Typed Name <br />/ I �.-7:• <br />J 15. International Shipments ❑ Export from U.S. Port of leavientryng <br />U.Si- <br />❑ Import to U.S. Date leavin .S.: <br />Transporter Signature for exports only): <br />cc 16. Transporter Acknowledgment of Receipt of Materials gignature <br />W r <br />Transporter 1 Printed/Typed Name i f <br />o <br />CL r, �t1.?.. Signature <br />z Transporter 2 Printed/ I yped Name <br />ccI17. Discrepancy <br />17a. Discrepancy Indication Space ❑ Type ❑ Residue Quantity <br />Manifest Referer <br />r 17b. Alternate Facility (or Generator) <br />J <br />U <br />LL Facility's Phone: <br />W 17c. Signature of Alternate Facility (or Generator) <br />F <br />Q <br />z <br />C7 <br />N <br />w <br />0 <br />16. Designated Facility Owner or Operator: Certification of receipt of materials covered by the manifest except as noted in•ltem 17a <br />Signature �) _ <br />Erinted./Typed Name <br />169 -BLS -C 5 11979 (Rev. 9/09) <br />❑ Partial Rejection <br />U.S. EPA ID Number <br />❑ Full Rejection <br />Month Day Year <br />Month Dav- YP4!_� <br />TRANSPORTER 0 <br />