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<br />169 -BLS -C 5 11979 (Rev. 9/09) TRANSPORTER #1
<br />NONHAZARDOUS 1. Generator ID Number 2 Pa 1 of
<br />3. Emergency Response 7!��173904
<br />WASTE MANIFEST T APPLICAi3LE
<br />5. Generalor's Name and Maslrlg Address Generators Site Address (if dUferent than mailing address)
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<br />Ganeretor Phone: 71% _ ;� S 1 D u< -r
<br />8. Transporter 1 Company N U.S. EPA ID Number 1 e
<br />MOT AP PLICABLE1
<br />-7--Transporter 2 Company Name U.S. EPA ID Number
<br />7 APPLICARE
<br />8, Designated FecBty Name and Site Address U.S. EPA ID Number
<br />RECOLOGY HAY ROAD NOT APPLICABLE
<br />6426 HAY ROAD - VACAVILLE, CA 95887
<br />-Ea-0218%—One:
<br />8. Waste1Shipping Name and Descdption
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<br />Tout
<br />12 Unit
<br />No.
<br />Type
<br />Quantity
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<br />13. Special Handing Instructions and Additional Inlonnetton
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<br />10. GENERATOR'SIOFFEROR'S CERTIFICATION:I 'hereby declare that the contents of this conslgwwl are fully and accurately, described above bythe proper shipping name, end are clasaFiad packaged,
<br />marked and labeled1*rarded, and are In aC respects in proper condition for transport according to app'Icab'e International and national govemmsntal regulations.
<br />Generetoes/Ofterors Prited>Typed Name Signature Mont Day Yaw
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<br />15.tntamatlonal Shipments 0 Import to U.S. 0 Exp try
<br />on from U.S. Pod of en !exit:
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<br />Trans rlerSi nature Lorexporls o Data leavkA U.S.:
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<br />18. TramporterAckn owledgmentof Rece¢r of Materials
<br />VTransporter
<br />1 Rinted/Typed Narre3
<br />8 Signature Month Day Year
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<br />Transpgrter Prfnt6dTyrWd Name Slgnaturev Month Day Year
<br />17. 01screpancy
<br />17a. Discrepancy Indication Space 0 Quantity 0 Type 0 Residue 0 Partial Rejedlon 0 Fug ReJedan
<br />Mari fest Reference Number:
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<br />17b. Altemate Faulty (arGenerator) { U.S. EPA ID Number
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<br />Facility's Phone:
<br />17c. Signature of Mefnate Facility (or Generator) r.. MonthDay Year
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<br />18. Aesignaled Facility Omer or Cperalor. Certification of receipt of matedais colremd by the manliest except as noted In ti 178
<br />PdntedT d Name e _ - Month Day Year
<br />169 -BLS -C 5 11979 (Rev. 9/09) TRANSPORTER #1
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