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C�R�REPUBLIC NOV 'AZARDOUS SPECIAL WASTE 8 3BESTOS MANIFEST <br /> 11►� SERVICES <br /> If waste is asbestostiwaste,complete Sections I,11, 111 and IV <br /> 1235177 <br /> If waste is NOT asbestos waste,complete Sections I,It and III <br /> 1. GENERATOR (Generator completes la-r) <br /> a.Genera r' U PA D Number <br /> 7 b.Manifest Document Number C.Page t of <br /> . F z <br /> d.Gengra Name and Location: L. f .5 (V. ' e.Generatof�fa/ilJ�ddr_ � <br /> A1,4 /�ry/�tp/�� / 7�G� �J( �/w// <br /> I. Phone: „�[ . 3/d � 1. d 4�G. g. Phone:241'� z <br /> If owner of the generating facility differs from the generatpr,provide: - <br /> h.Owner's Name: !.Owner's Phone No.: <br /> j.Waste Profile# k. Exp. Date 1.Waste Shipping Name and m.Containers n.Total o. Unit <br /> Description No T Type Quantic Wt/Vol <br /> til <br /> C E VIRONENTAL <br /> GENERATOR'S CERTIFICATION: I hereby certify, at the abpve named material is not a hazardous waste as defined by 40 C 1 br a a tic <br /> state law,has been properly described,classifleV.zin `pp agkd.,and is i proper condition for Jrahsportation according to applicable regulations;AND, if this <br /> waste is a treatment residue of a previously restricted hal rdou``sS waste ubject t the Land Disposal Restrictions. I certify and warrant that the waste has <br /> been treated in accords a with the requirements of 40 CFR 268 4ad' nalon r waste as defined by 40 CFR 261. <br /> Am / ©� <br /> p.Generator Authorized Agent Name Print nat leIr. Date <br /> II. TRANSPORTER Generator com le Ila-b and Trans orte com letes Ilc-e <br /> a.TranspoWTeWqntddress: kr S� / <br /> P.O Box 367 f� <br /> Lddl,CA MAI 20032M481 ,) [ � 2 � `1 �,✓ SC.S/ <br /> b. Phone: <br /> & v av ! , N2 ©/ <br /> c.Driver Name(Print) d. i nature e. Date <br /> III. DESTINATION (Generator complete Illa-c and Destination Site completes Illd-g) <br /> a. Disposak;ffi&@e Address: c. US EPA Number d. Discrepancy Indication$pace: - <br /> 9989 S Austin Rd <br /> Mentem,CA 95338 208- <br /> 4 <br /> to <br /> e that the above named material has be e ed to the best of 'kno ed q e the foregoing is true and accurate. <br /> e. a e of Authorized Agent rint I. Signature - 1 9. Date <br /> IV. ASBESTOS (Gen a or completes IVa-f and Operator complete IVg-i) <br /> a.Operator's Name and Address: c. Responsible Agency Name and Address: <br /> b. Phone: d. Phone: <br /> e. Special Handling Instructions and Additional Information: <br /> f.❑ Friable ❑ Non-Friable ❑ Both % Friable %Non-Friable <br /> OPERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully..and accurately described above by the proper shipping name <br /> and are classified, packaged, marked and labeled/placa;dad,and are in respells in proper condition for transport according to applicabfe international and <br /> national governmental regulations. <br /> .O emtoQ Name and Title Print h. Signature I 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 /> REV 12/10 RETURN TO OPERATOR f RS-F11A <br />