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169 -BLS -C 5 11979 (Rev. 9/09) TRANSPORTER #1 <br />NONHAZARDOUS <br />WASTE MANIFEST <br />1 •Generator ID Number <br />NOT APPUCABZE <br />2. Page of 3. Emergency Respor>Se Bane <br />4. Waste Tracking Number, <br />173901 <br />3. �pporalprs 7T 1 ng -Address Generators Slle Address <br />etArC�J��S (if different than mailing addr <br />41 <br />Generators Plana: t S <br />6. Transpo ter 1 Company Name <br />U.S. EPA ID Nwnber <br />NOT APPUCABLE <br />_ <br />7. Transporter 2 Comperry Name . ~ <br />® t✓ C) S 50\ U.S. EPA ID Number <br />♦ �C LICAI�E i4 <br />8. Designated Faa7rymo and Site Address U,�O�EPA D� er <br />RECOLOGY HAY ROAD. NOT APPLICABLE <br />�2E HAV' ROAD- VACAVILLE, CA X887 <br />Fast s Phone: <br />9. Waste Shipp ng Name and DescrlpUcn 10 Contehers 11. Total 12. Unit <br />No. Type Ovent ty WL/Vol. <br />PC <br />•+fr <br />Z. <br />tL <br />n. <br />•�(.Rr <br />f <br />d•, S. <br />2. <br />1 i. <br />1 4 t'g i1rM'at <br />p�` i• 9 bi <br />hd. `y mac. aNry . <br />113. <br />Spedal Handling instructlons and Additional Infornatlon `- <br />14: GENE RATOR'SMFFEROR'S CERTIFICATION: I hereby dedare that the contents of this consignment are "and accurately described above by the proper shipping name, and are da3stied, packaged, <br />marked and labeled/placarded; and are In et respects in proper condition for transport accw&V to applicable international and national govemmentalregulalions. <br />Generator's(GlfarorsPrinle&TypedName Signal re &b-0 Day a Year <br />J ��9 a 57�- R A i ee C 0 E� <br />IS. Intamaticnel Stypments <br />❑ Impod to U.S. ❑ Export from Pod of entry/ext'" <br />Transporter Si natt.Te for exports only): Date leavin U.S.: <br />Ir W <br />16: Transporter Ad=Medgment of Receipt of Mateeals <br />Trerr 1 Pn�ladryypedlNam Signature fAonlh Day Yeef <br />IU) <br />T.(ansponer2 Prlmedrryped Name ��j -= — Sign ure Month Da Y r <br />��. 7. <br />17. Discrepancy <br />17a.; btscrepancy Indkallon Space ❑ Quantity ❑ Type ❑'Residue Portal Refection ❑ Full ftejedlon <br />Manifest Reference Number: <br />17b, Alternate Fadtty (or Generator) U.S. EPA ID Number <br />Y <br />Facthys Phone. <br />®• <br />F <br />170. SVikae of AAemate Facility (orGenerator) Month Day Year <br />O <br />0 �yV <br />"rev �r]i � r.N!. �i�;;yy � Y :� i!i�{ 1 }» Isk qt7Y. ��rl Yi�vh �(i' 3.. •;" :� i Y.. 4:1 t �Y 4 ., 'i +T«.'" w <br />i{� i���� M1.� `.♦T� �1FTY h' R,»y^�r %���._ � T •^ �1, ( i�J 1��'�.� 4 � l��r� �� <br />�r'L <br />5.,tw <br />.t � "4 <br />i`i'i tt�itr •.)p 7f (: �ir"y ib � �i" .,'s�k�i -_.j W.t`d ak'. <br />NY f>,•,...jj33rri((�� .fl•iyj1, iY• V •k ! « i L�.' '1 Th.: V4Ki. fr,e <br />h1.FY'��1))%,�,yy,,. � r ��qc <br />�(' �(n/' � ��( <br />� <br />K. <br />, <br />h(�`R.7aZ. L�l�.Y5+. �'r�i�.Cai>�ts'1� ::k�n`i,y'r„k• ,v4..pF. y�7���� y:. �� h '�,t i <br />Cu.'Y~. •q„i_�. 'R'iyy: L -.;rid i�n 4. - � 'K- tiS': ;4.Q+.. t.-b'."�',h <br />�L". <br />.16.1kgteted <br />Faclttyi Owner.or Operator. Cerffficetlon of receipt of materiab covered by the manifesl except as noted In Item 1 er+ 7 <br />dName Month Day Ye <br />A,. <br />Gj <br />169 -BLS -C 5 11979 (Rev. 9/09) TRANSPORTER #1 <br />