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1Rla-RI,_Ir,c s 11979[Rev s10x1 TRANSPORTER #1 <br />NON -HAZARDOUS 1. Generator ID Number <br />2 Page 1 of <br />3. Emergency Response Phone <br />4. Waste Tracking Number <br />WASTE MANIFEST NOT APPLICABLE <br />176894 <br />5. Generator' Name and Mailing Address <br />v� 4C �f11w <br />Generators Site Address (if different than maion address) *� <br />�6�Quo <br />te ,. <br />Gbiferem(a hone: / C � <br />�(� �' <br />8.7ranspo er 1 Company N <br />e <br />y <br />S. EPA ID Number <br />I�) <br />NOT APPLICABLE <br />7. Trdnsp er 2 any me <br />U.S. EPA ID Number <br />NOT APPLICABLE <br />8. Designated Facility Name and Site Address <br />U.S. EPA ID Number <br />RECOLOGY HAY ROAD <br />�;. : � NOT APPLICABLE <br />6426 HAY READ - VACAVILLE, CA <br />Facdt s Phone:(707) 67&4718 <br />9. Waste Npping Name and Descriitfon <br />`t, <br />10. Containers <br />11. Total <br />12 Unit <br />ti, <br />No. <br />Type <br />Quantity <br />M Vcl. <br />yy <br />4 <br />Y <br />• 1, <br />LIJ <br />2. <br />33, <br />TtiRf <br />13. Special Hw d6ng instructions and Additional Infotmalton <br />14. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare thatthe contents. of this consignment are fuC and accurate y described above by the proper shipping name, and are classified, packaged, <br />marked and labeledrplacardeii, aridere PNII respects In proper condition for transport according to applicable iritamational and national governmental regulations. <br />G�enerrabor'slOfferoes PnnteOyped Name <br />Signature. Mon h Da <br />l�Gt ilfior>al� SLo <br />(�� <br />15. IntemaShipments Q Imam to U.S. ❑ Exp cd from U.S:`-"� Port olentry/axtt: <br />— <br />Transporter Signature for exports only): <br />Dale lea*U.S.: <br />¢ <br />18: Transporter Adknowtedgment of Recelpt of Materials <br />Transporter 1 PrinteNT ed Name GSignature <br />i <br />Month Da Year <br />' <br />o <br />� <br />_ <br />ra S V ob <br />T r2 to yped Name <br />Signature Month Da Year <br />I <br />r <br />17. ftcreparicy <br />17a. Discrepancy Indloadon Space Quaff <br />Quantity ❑ Type <br />❑Residue ❑ Partial Re ectlon <br />) ❑ Fill Rejection <br />Manifest Reference Number: <br />17b. Altemate FaciRy (orGenerator) <br />U.S. EPA ID Number <br />aL <br />Facility s Phone: <br />17c. Signature of Alternate Facility (or Generator) <br />Month Day Year <br />•'$6� r1 r :�' 'Lr ql ,p, .�)F �` i IcY"SA", <br />98. Designated Facility Owner or Operator. Cerf(flcation of receipt-afmatedsla covered by lhe manifest except as noted in Item a <br />krl ed Name, <br />a - M D@tfi <br />17 <br />1Rla-RI,_Ir,c s 11979[Rev s10x1 TRANSPORTER #1 <br />