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4 <br /> Published by J.J.KELLER&ASSOCIATES,INC o,Neenah,WI-USA-(800)327-6868-jjkeller.com-Printed in the United States <br /> NON-HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Waste Tracking Number <br /> WASTE MANIFEST NOT APPLICABLE -�- <br /> 5.Generator's Name and Mailin�t Address Generator's Site Address(if different than mailing address) <br /> 4 / <br /> Generator's Phone: / CV ( 1 }7C <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> NOT APPUCABLE <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> NOT APPLICABLE <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> RECOLOGY HAY F1rOAD NOT.APPLICACLE <br /> 6426 HAY ROAD-VACAViLLE,CA 956$7 <br /> Facility's Phone: (7M 678-4718 <br /> ta <br /> 9.Waste Shipping Name and Description 10.Coniners 11.Total 12.UnitNo. Type Quantity Wt.Nol. <br /> cc <br /> O ti <br /> UJ <br /> z 2. <br /> W <br /> CS <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 aw'In all respects in proper condition for transport according to applicable international and national governmental regulations. <br /> Generators/_Qfferor's Printed/Typed Name Signature Month Day Year <br /> _ <br /> J 15.International Shipments <br /> H ❑Import to U.S. ❑Export from U.S. Port of entry/exit: <br /> Transporter Signature for exports only): Date leaving U.S.: <br /> cc 16.Transporter Acknowledgment of Receipt of Materials <br /> ¢ Transporter 1 Printed/Typed Name p `'-Signature Month Day Year <br /> 0 <br /> a t"'A , vv-, 1Cn <br /> zTransporter 2 Printed/Typed Name 1 Si attlCe Month Day Year <br /> r ! <br /> 17.Discrepancy <br /> 17a.Discrepancy Indication Space <br /> ❑Quantity El Type El Residue El Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> F 17b.Alternate Facility(or Generator) f U.S.EPA ID Number <br /> J <br /> U <br /> rai Facility's Phone: <br /> W 17c.Signature of Alternate Facility(or Generator) Month Day Year <br /> zz <br /> cs <br /> 18.Designated Facility Owner or Operator:Certification of receipt of materials covered by the manifest except as noted in Item 17a <br /> ` Printed/Typed Name Signature Month Day Year <br />