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NON -HAZARDOUS 1. Generator ID Number 2 Pa e 1 of 3. Bnergency Response Plane 4. Waste Tracking Number <br />WASTE MANIFEST NOT APPLICABLE 176891 <br />5. Genera a N end Meiln dines <br />Generator's Site Address dlffererd than m ling address) <br />M(q r�, t Inc <br />8. T spot 1 TO Comps P r U.S. EPA ID Number <br />U.S. <br />-, NOT APPLICABLE <br />7. TrffWjr 2 C&npany NI—arng U.S. EPA ID Number <br />NOT APPLICABLE <br />B. Designated Facility Name and Ste Address U.S. EPA ID Number <br />E I <br />RECOLOGY HAY ROAD NOT APPLICABLE <br />6426 HAY ROAD - VACAVILLE, CA 95687 <br />Fadi s Plane: (707) 678-4718 <br />I10. <br />9. waste Shipping Name and Description <br />Containers <br />11. Total <br />112.Urill <br />No. type <br />Duantity <br />wuvol. <br />1 <br />2 <br />3. <br />t ••'�: <br />r <br />� , <br />13. Special Handing instructions and Addlional Information <br />14. GENERATOR'S/OFFEROR'S CERTIFICATION: I hereby declare that the contents of <br />tlus consignment are fully and accurately described above by the proper shipping name, and are alassifed, packaged, <br />marked and laboWplacanded, and are in all respects In proper condition for transport accon:1 b applicable international and national governmental regciatfons. <br />s/O(t a Pdnted/Typed Name <br />- Sign aluMonth <br />D e <br />15. International S Ipmib <br />❑ Import to U.S. <br />n�t <br />LJ 6pfioit from U.S. Pori of entry/exit <br />Transporter Signature fors orts o : Date leaving U.S.: <br />18. Transporter Acimowledgmenl of Receipt of Materials <br />Tres rtsr 1 Prhn ed Name ` <br />Signa <br />Month pay <br />KI11 (k <br />!fi <br />w <br />TraAxherg rr9teeypZdNanne <br />Slgnat re <br />onfh ear <br />17. Discrepancy <br />17a. Discrepancy Irmdicaion Space ❑ Ouandly ❑ Type <br />❑ Residue ❑ Partial Rejection ❑ Full Rejedlon <br />Manifest Reference Number. <br />17b. Alternate Facility (or Generator) <br />U.S. EPA ID Number <br />U' <br />LL <br />FaciAys Phone: <br />17c. Signature of Alternate Facility (or Generator) <br />Month Day Year <br />a <br />z <br />� <br />wr}idy]�,x <br />0 <br />ii'y t '{ tr� N'�1:�" ,. �a � .P .. J � v,G "N - �hk,� �. l;. -: �ti. Y N•�" _r -n <br />F 9[ q R � �A� V T+ �i�' I f' f � a1n. ?. • T`�� 'T SSU <br />�.�[�jt�.�`�` <br />"� �'+•T •}, <br />� TF '� <br />X<.7. �,. %'k<✓N. 9k��S#1•M,'4 r":R :"'�L' .•" Y <br />���yy'Bk�G'.: _ �F �� � <br />- 1���:.. <br />18. Designated Facility Owner or Operator.. Certif ation of receipt of matedais covered by One manifest except as no d In Item 17a <br />PrintediTypedName <br />Signatu <br />Mort Day Year <br />69-911-5-G 5 11979 (Rev. SIM) ' - nF.girmaTFb FdClt ITV TA f`FarGo ATne <br />