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169 -BLS -C 5 11979 (Rev. 9/09) TRANSPORTER M <br />RDOUS <br />1. Generator ID Number <br />2. Page 1 of 3. Emergency Response Phone�Wasteng <br />Number <br />NIFEST <br />T ,{1PPUGAaE <br />_ <br />FGenecators <br />me and Mailing Address <br />aL � <br />r/ <br />Generators Site Address (if different than mailing address) <br />_� fr. a wa s <br />V, ��;,.5 <br />����i7�.Ti� <br />S -f <br />i T1 R, e,n r c, c� f G <br />l 6 r 6 ane. cc) IG e 4Z <br />Generators Phone: 7 (.;--1 ? / . <br />e . <br />c7 , 1 ri Vii\ <br />6. Transporter 1 Company Name <br />U.S. EPA ID Number <br />1VIOT <br />APPLICABLE <br />2 Company Name <br />U.S. EPA ID Number <br />FTranspod:er <br />ed Facility Name and Sile Address <br />U.S. EPA ID Number�A�iE <br />iT APP1. CABLE <br />7 �2ggINO <br />1•S HAY ROAD - VACAVILLE, CA JJVD7 <br />Facili 's Phone: <br />9. Waste Shipping Name and Description <br />10. Containers <br />�Total <br />12. Unit <br />No. <br />Type <br />Wt.fvol. <br />✓e.7 a . Jo U S, I r t <br />W <br />W <br />2. <br />l <br />c7 <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 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 />Generalors/Offerors Printed/Typed Name <br />S gnature / f Month Day Year <br />–1 <br />15. International Shipments <br />11Import to U.S. ❑ Export from U.S. Port <br />t <br />— <br />Transporter Sier nature for exports only): <br />of entrylexit: <br />Date Ieavino U.S.: <br />16. Transporter Acknowledgment of Receipt of Materials <br />Transporter 1 Printed/Typed Name <br />Q <br />O <br />r� �� t <br />Signature Month Day Year <br />'7 <br />Q <br />Transporter 2 Printed/Typed Name <br />Signature Month Day Year <br />17. Discrepancy <br />17a. Discrepancy Indication Space <br />❑ Ouantity ❑Type <br />Residue ❑ Partial Rejection ❑Full Rejection <br />Manifest Reference Number: <br />17b. Altemate Facility (or Generator) <br />U S. EPA ID Number <br />J <br />U <br />aL <br />Facility's Phone: <br />w 17c. <br />Signature of Allemale Facility (or Generator) <br />Month Day Year <br />a <br />z <br />O <br />W <br />18. <br />Designated Facility Owner or Operator: Certification of receipt of materials covered by the manifest except as noted in Item 17a <br />Printed/Typed <br />Name <br />Signature Month Day Year <br />169 -BLS -C 5 11979 (Rev. 9/09) TRANSPORTER M <br />