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i <br /> �P fir-REPUBLIC NON '4AZARDOUS SPECIAL WASTE & ASBESTOS MANIFEST � <br /> rI+• SERVICES, INC. Q <br /> tf waste is asbestos waste,complete Sections I,11,111 and IV <br /> If waste is NOT asbestos waste,:oomplete Sections 1.Rand III <br /> z <br /> I. z GENERATOR (Generator completes ]a-r) <br /> a.Generator's US EPA 10 Number b.Manifest Document Number G Page 1 of <br /> NIA 1 <br /> d.Generator's flame and Location: e.Generator's Mailing Address: <br /> Valero Marketing and Supply Company(Vataro Station#13782) Valero Marketing and Suppily Company(Valero Station#13792) <br /> 2255 S.Airport Way 10955 Westmoor Drive,Suite 400 <br /> Stockton,CA 95206 Westminster,CO 80021 <br /> f.Phone:303-379-3081 g.Phone:30 -379-3091 <br /> If owner of the generating facility differs from the generator,provide: <br /> h.Owner's Name: i.Owner's Phone No.: <br /> 1.Waste Profile# k.Exp.Date I.Waste Shipping Name and m.Containers 1 n.Total o.Unit <br /> -Descr tion No_ Type Quantity VA/Vol <br /> CY <br /> 42041319808 11101!14 Soil WIDebris <br /> GENERATOR' CER nFICPMON: I hereby certify that the above named material is not a hazardouswaste as defined by 40 CFR 261 or any applicable <br /> state law,has been property described,classified and packaged,and Is in proper condition for transportation according to applicable regulations,AND,if this <br /> waste is a treatment residue of a previously restricted hazardous waste subject tot nd at Restrictions. I certify and warrant that the waste has <br /> been treated in acoordance with the requirements of 48 CFR 268 and is no loncierAfharardopewaste as defined by 40 CFR 261. <br /> GerferatorAuthorized AcIent Name Print Slanature r.Date <br /> II. TRANSPORTER Generator completes I la-b and Transporter completes 11c-e) <br /> a.Transporter's Name and Address: j,A �j4r�,irsp©!L %7F r4� <br /> �P Q�iY� LvF]Co <br /> 6.4- <br /> b.Phons:049413MM 3`!v—57 -X91 <br /> �r� SCrtr*'ll"r/'�+r"�— ,.<..r <br /> c.Ddwr Name Print I d.Si natu e.Rate <br /> III. DESTINATION (Generator complete Illa-c and Destination Site completes Illd-g) <br /> a.Disposal Facility and Site Address: c.US EPA Number d.Discrepancy Indica ace. <br /> Forward Landfill <br /> 9995 S.Austin Rd. <br /> Manteca,CA 95336 <br /> b-Phone:209-982-4298 <br /> d r A Y <br /> I herby cerft that the above named material has bbeh aqa6ptgfd an a belog* owted the foregoing is Aend cc <br /> e.Name of Authorized ent t naturd/ ate <br /> IV. ASBESTOS (Generator completes)V2 f and Op6rator com etc lVg " <br /> T opefator's Name and Address: c.Resp y Name and Address: <br /> b.Phone: r#.Phone: <br /> e.Special HarRirtg lnstruciions and Additional information: <br /> f.0 Friable Non-Friable El Both %Friable %lion-Friable <br /> OPERATOR'S CER11FICATION:I hereby declare that the contents of this consignment are fully and accurately described above by proper shipping name <br /> and are classified,packed,(narked and labeled and are in all respects In proper condition for transport by highway according to applicable international and <br /> national gWerrimental regulations. <br /> a.Operator's Name and T@e Tint h.Signature i.Date <br /> 'Operator refers to the company which owns,leases;operates,controls,or supervises the facility being demolished or renovated,or the demolition or <br /> renovation operation or both <br /> { <br />