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Cr <br />0 <br />a <br />rr <br />Lu <br />z <br />W <br />c7 <br />I <br />7 •r ti ,, ) n( 1C7 <br />NON -HAZARDOUS 1 Generator ID Number 2. Page 1 of 3. Emergen�Response <br />�4.ste Tracking Number <br />WASTE MANIFEST r'mcs y' .fit.��;riC �y .36/-'J •, , '9 <br />5. Generator; s Name and Mailing Address: 7 <br />_77 _ U ,y/ y+ tli � 1 Generator's Site Address (if different than mailing addre§s) <br />-.Ln o - 1 c 1 G, I G1,: i.(,1(/,�j LiUV!•i,I'ii.�d'• �! - �_ '-� i - i�,rX <br />Y7 P-0 C , GL j� <br />Generator's Phone: ?;; / - 71` ,= -7 I S- J< �\ r f- <br />6 Transporter 1 Company Name <br />U.S. EPA ID Number <br />7. Transporter Company Name �`' `.I �-j�✓ <br />j U.S. EPA ID Number <br />8. Designated Facility Name and Site Address <br />U.S. EPA ID Number <br />HAY ROAD - VAOAVIi_LF. CA a9AA7 "; r <br />=acility's Phone: `707)678-4716 <br />L <br />Name and Description <br />V,:f c., «u5 er,7ifGvoC i <br />3. <br />4. <br />13. Special Handling Instructions and Additional Information <br />10. Containers 11. Total 12. Unit <br />No. Type Quantity Wt.Nol. <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 />Lmar'l,el,l, and labeled/placarded, and are in all respects in proper condition for transport according to applicable international and national governmental regulations. <br />or s/Offeror s Printed/Typed NameSignature <br />Month Day Year <br />aonal Shipments ❑ Import to U.S. ❑ Export from U.S. Port of entry/exit: <br />er Si nature for ex orts onl <br />16. Transporter Acknowledgment of Receipt of Materials Date leavin U.S.: <br />Transporter 1 Printed typed Name Signature <br />Month Day Year <br />Transporter 2 Printed/Typed Name f'` i' ="✓�xy <br />f Signature Month Day Year <br />17. Discrepancy <br />17a. Discrepancy Indication Space <br />❑ Quantity ❑ Type ❑ Residue ❑ Partial Rejection <br />❑ Full Rejection <br />17b. Alternate Facility (or Generator) Manifest Reference Number: j <br />U.S. EPA ID Number <br />I <br />Facility's Phone: + <br />17c. Signature of Alternate Facility (or Generator) <br />Month Day Year I! <br />1 <br />t <br />I <br />+ <br />s <br />18. Designated Facility Owner or Operator: Certification of receipt of materials covered by the manifest except as noted in Item 17a <br />PrinledfFyped Name Signa <br />/,�i itr . •^:r7�i Month Day ear, <br />_. <br />BLS -C 5 11979 (Rev. 9/09) <br />TRANSPORTER #1 <br />