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169 -BLS -05 11979 (Rev. 9/09) TRANSPORTER #1 <br />NONHAZARDOUS 1 1. Generator ID Nurtber 2, Page 1 of <br />WASTE MANIFEST NOT APPLICABLE � <br />3. Emergency Response Phone 4. Waste Tracking Number <br />1.7 6 8 9 3 <br />5. Generat s and Meifin Address Generator's Site Address (if different than mailing address) <br />1 v � r'� Wfv�zy �G�7 <br />C6t, <br />General a Pho 1, dCAL <br />6. Tran der Company ame S. EPA Il) Number <br />NOT APIPUCABLE <br />7. Tre 2 Comps N U.S. EPA ID Number <br />NOT APPLICABLE <br />8. Designated Facility Name and Site Address U.S. EPA ID Number <br />RECOLOGY HAY ROAD NOT APPLICABLE <br />6426 HAY ROAD a VACAVILLE, CA OWN <br />Fed a Phone: 0 678 -Cl 18 <br />9. Waste ShippingName and De Ptico <br />1D.'C ntainers <br />11. TWeI <br />12 Unit <br />No. <br />T <br />Ouantity <br />WUVoi., <br />W <br />ewe F <br />4. w <br />13. Special Handing 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 classiffed, packaged, <br />marked and labeledrplacarded, and are In all respects In proper condition for transport ad6ording to applicable International and natlonal govemmental regulations. <br />Genera}toes/Offeroes Printeciiryped Name Sign etur . Day Year <br />15. International Shipments <br />❑import to U.S. ❑Export from U.S. Port of entry/epC <br />Transporter Snature for experts on : Date leaving U.S.: <br />16. Transporter Admowledgment of Receipt of Materials <br />Tra der 1 PrintedTyped Name d r Signature Month Day year <br />(L <br />6 <br />Trarter 2 do a Signa th 'Day Mr <br />17. Discrepancy <br />17a. Discrepancy Indication Space ❑ Quantity ❑ Type ❑Residue ❑ Partial Rejection ❑ Full Refection <br />Manifest Reference Nmntber: <br />17b. Alternate Facility (or Generator) U.S. EPA ID Number <br />a <br />a <br />Facility's Phone: <br />17c. Signature of Aftemate Facility (or Generator) Month Day Year <br />�'� <br />�1. N }Hill; <br />O4 E 1rF `\ •r J II'. 1 i ,� i �'ir, { I y f i�' <br />i $t� 8 +�i ` �'�•� )y \ ?�'t'„U�i ��f`c r} Y�� � Td ��`� tFs C�'� ': 't �"�k t: f} , '� � �'' -kh �� �C r���r, rri� R , � ,j�, <br />'�:'F.a'? �,?41 <br />• _�.�.' ".X@. . '�" .».� .'}.. .�� ri-. �,.�rfi y' �S :+�: k.?. w.'�A. ➢� • "�� �\ttit.. i,})1���. <br />18. Designated Facili Owner or Operator. Certification 4receipt of materiels covered by the manifest except as noted in Item 1 a <br />YPed Name r �` <br />CI I M�Ih I / I Yea <br />169 -BLS -05 11979 (Rev. 9/09) TRANSPORTER #1 <br />