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169 -BLS -C 5 11979 (Rev. 9/09) TRANSPOR T i=R #"1 <br />NON -HAZARDOUS <br />1. Generator ID Number <br />2. Page 1 of <br />3. Emergency Response Phone <br />4. Waste Tracking Number <br />WASTE MANIFEST <br />NOT APPUCABLC <br />-c -7 _ —7; c, _ S -, <br />f /^ <br />5. G_eneraloes Name and Mailing AddressC) tlyNhh <br />Generator's Site Address (if different than mailing address) <br />i 6 4 C,tn e_ ­r o <br />Generalor's Phone: I , -7 - <br />6. Transporter 1 Company Name <br />U.S. EPA ID Number <br />7. Transporter 2 Company Name <br />U.S. EPA ID Number <br />8. Designated Facility Name and Site Address <br />U.S. EPA ID Number <br />i'vU 1 i Y Li4 ABLE <br />f eg 1f3 'qAY ROAD VACAViL E, CA 95687 <br />Facility's Phone: t f S; 171 8 <br />9. Waste Shipping Name and Description <br />10. Containers <br />11. Total <br />12. Unit <br />No. <br />Type <br />Quantity <br />WLNot <br />_j ( ( <br />1 (1.,10 A ' �'G Lo, IJ O i� e c <br />w <br />z <br />w <br />2. <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 <br />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 />Ge nerator's/Offeror's Printed/Typed Name <br />Signature j Month Day Year <br />_J <br />i— <br />15. Intemational Shipments <br />❑ Import to U.S. <br />❑ Export from U.S. Part <br />of entryleAt: <br />Transporter Signature for exports only): <br />Date leaving U.S.: <br />¢ <br />w <br />16. Transporter Acknowledgment of Receipt of Materials <br />¢ <br />Transporter 1 Printed/Typed Name, <br />Signature j j /" Month Day Year <br />z <br />Transporter 2 Printed/Typed Name <br />Signature Month Day Year ' <br />� <br />1 <br />17. Discrepancy <br />17a. Discrepancy Indication Space <br />❑ Quantity El Type <br />❑Residue ❑Partial Rejection E] Full Rejection <br />Manifest Reference Number: <br />H <br />J <br />17b, Alternate Facility (or Generator) <br />U.S. EPA ID Number <br />U <br />rai <br />Facility's Phone: <br />w <br />17c. Signature of Alternate Facility (or Generator) <br />Month Day Year <br />r <br />a <br />z <br />0 <br />rn <br />w <br />0 <br />18. Designated Facility Owner or Operator. Certification of receipt of materials covered by the <br />manifest except as noted in Item 17a <br />Printed/Typed Name <br />Signature Month Day Year <br />169 -BLS -C 5 11979 (Rev. 9/09) TRANSPOR T i=R #"1 <br />