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PHOT E 110. 90-2 9183
<br /> JLII. 1 12-
<br /> 0 T.
<br /> .N0N7HA.ZARD0bS:APEC1AL WASTE 0•A�:iiiiiiiidEST(
<br /> Iff waste is asbestos waste.complete Sections I.H.TIT and TV
<br /> 11 waste is NOT asbestos wasts,complete only Sections 1.17 And Ill. b
<br /> of
<br /> ;. :^)rAROO , )
<br /> Generator Name: vRom'-Ts cmpvory Ar-r.Q SWTr,.W
<br /> b. Generating Location:
<br /> PW 5077 Ila M-
<br /> Address d. Address:
<br /> U'Jl--a VAPX, CR 9C.622-5077
<br /> Phone No.:--,,. (525) 29c-8891 f. Phony No.: Cf/A
<br /> owner of the generating facility differs from the ;an,.,., provide:
<br /> I- Ownaes!Npme; S--A%e aX 1(13)
<br /> h. Owner's Phone No.: TYPE
<br /> BF1 WASTE CODE 4 y 9 9 2 U Containers DM-METAL DRUM
<br /> DP -BAG-PLTIC DRUM
<br /> AS
<br /> Description of Waste: 5k. Quantity Uni's NO, TYPE BA ,6 MIL,PLASTIC BAG
<br /> MI. M WRAP
<br /> T -TRUCK
<br /> 0 -OTHER
<br /> GENERATORS CERTIFICATION: I h1ebY I.nity Th.,the QDa,e h,r,Md,,a,oj*I Is nor.hazardous waste 14 delmod by 40 CFR Pan 261 or UNIT
<br /> any APPI—bl- erste le-. Ties been properly daootbed.cisssirand pad,apad,and I.in proper on,dr,,n far.... ,',do, eIng to P -POUNDS
<br /> appr�at;14 regulations:AND.it Th. W.treatment residue of a previottaty reentowd haaeard.a waste lmj�,,1.Th.L.ZZ=Posai Y -YARDS
<br /> T1,eMq.veTrnmta.(3OCFR Pan 268 and la n0 longer aI
<br /> h�a�llswwteasdeft.,,db,�GFR Part 211- ?I t. the r1mig'ast of M--co Prtexxfara 064ANX M -CUBIC METERS
<br /> Y* -CUBIC YARDS
<br /> Mint 7srA xxim/- EF 10 -OTHER
<br /> G.n.,.r A,qhorized'Agent hr,rnc .'n.. Shion,eni Date
<br /> 30�1-5 fe..
<br /> 'r
<br /> M. e;
<br /> TRANSPORTER TRANSPORTER 11
<br /> Name:A
<br /> th. Name;
<br /> Address: I. Address:
<br /> Driver Namefrtrle:;
<br /> Phone No.: Tf. Trui*'No*'-V f k. Phone No
<br /> I. Truck No
<br /> Vehicle License No./SMW-
<br /> m.Vehicle License NO./State;
<br /> Ackrvowlaciigernervt of Receipt of Materials. Acknowledgement of Receipt Of Materials.
<br /> I1•
<br /> IT.
<br /> shipr..,[Deft
<br /> Site Name- V.�) KUAV SA�wl'!Zwf 1—&NDF2jj' (925) 64?-0$9 .•
<br /> C. Phone No.;
<br /> Physical Address; RM--"Physical
<br /> t.zv'.
<br /> .yj�, CA 94550� d. Mailing Address
<br /> L1VX4t-j0P.:.. 4:.*A j--N55&
<br /> Discrepancy Indication Space:
<br /> I hereby certify That The above named material has been accepted and to The best of my knowledge The foregoing is True and accurate.
<br /> E-CIS 09-30308
<br /> rVn+d emeses,Agent s�anernra ..
<br /> Aaosip[Date
<br /> Shipperss'S.Name:
<br /> D. ShippeTs's-Phone No.:
<br /> Shippers's*Address:
<br /> Shipperses Special Handling Instructions and additional information!
<br /> '1iTJF1CA`F/09V:'"I"hereby dealers that the rnnteriu of this consignment era lolly and accuNrely described
<br /> .•ked.arta labeletl/placarded,and are In all respects In proper condi[Im1 Im vanspon according tq applicable above by proper shipping name and are 0183sified. package,
<br /> mational and national governmeotal regulations._
<br /> ShiPPe,a's' Name&Title; IJyLJ
<br /> -F77-1
<br /> Name and Add,,,,
<br /> of Responsible Agency:
<br /> Friable: E) Non-friable: ❑ Both
<br /> friable ---- ----
<br /> nonfriabe
<br /> Me..MnV Zhieh owns.leases.otwales,oontrois•or.uoefvi"s me Mcilitv being demolished or renovated.or the darpolidon or re,,.v.v..,oparavon,
<br />
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