Laserfiche WebLink
f <br />e"MIREPUBLIC NOHAZARDOUS SPECIAL WASTAASBESTOS MANIFEST <br />Z�04 SERVICES <br />1235141 If waste is asbestos waste, complete Sections I, II, III and IV <br />If waste is NOT asbestos waste, complete Sections I, II and III <br />I. GENERATOR (Generator Completes la -r) <br />a. Generator's US EPA ID Number <br />N/A <br />b. Manifest Document N mbar <br />LAn 9 <br />c. Page 1 of <br />d. Generators Name and Location: <br />11 'j, M TNDtoG <br />►533 . t, -A 4-b.s Aq ST <br />e. Generator's Mailing Address: <br />lim Th=,e011, Inc <br />P O Box 367 <br />L Phone: <br />g. Phone: Lodi, CA 95241 209-3295481 <br />If owner of t e generating facility differs from the generator, rovide: <br />9989 9 Austin Rd <br />h. Owner's Name: <br />I. Owner's Phone No.: <br />I. Waste Profile # <br />k. Exp. Date <br />I. Waste Shipping Name and <br />Description <br />m. Containers <br />I herebvicertitvthat the a bove named material has <br />n. Total <br />Quantity <br />o. Unit <br />Wt/Vol <br />No. I <br />Type <br />QQ11Ii&J4% <br />Debris <br />Tons <br />F? <br />C <br />GENERATOR'S CERTIFICATION: I hereby certify that the above named mater: I is not a hazardous waste as defined by 40 CFR 261 or any applicable <br />state law, has been properly described, classified and packaged, and is in prop condition for transportation according to applicable regulations; AND, if this <br />waste is a treatment residue of a previously restricted hazardous waste subject t the Land Disposal Restrictions. I certify and warrant that the waste has <br />been treated in accordance with the requirements of 40 CFR 268 a n� a hazard le as defined by 40 CFR 261. <br />y. u icwwi ruuiunceu �gnm Intl I q. , i nature " I r Date <br />a. Transporter's Name and Address: <br />,Jim Thorpe Oil Inc. <br />P 0 Box 367 <br />h_Phnne•Loci, CA 95241 209-329-64$1 a /1 <br />III. DESTINATION /(,enarafnr r.mmnlata Ala -r vinei I)o.fin>1rs,T, Qif. wa -1 -- <br />a. Disposal Facility and Site Address: <br />i <br />c. -EPA Number <br />d. Discrepancy Indication Space: <br />Forward Landfill <br />/US <br />OPERATOR'S CERTIFI ATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name <br />9989 9 Austin Rd <br />national governmental regulations. <br />b. P4anteca, CA 95336 -208-, 2-4298 <br />L 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 />I herebvicertitvthat the a bove named material has <br />been acceded ed and to theI be; -of my knowledge the foregoing <br />is true anq a ate. <br />e. Nam of AuthorizM Xqentkprintt 111. <br />Si nalu e <br />IV. AUBF-ST05 yienerator Compleleg IV arld Opej`dtor Complete IV9-I) <br />a. Operators Name and Address: V <br />c. Responsible Agency Name and Address: <br />b. Phone: <br />d. Phone: <br />e. Special Handling Instructions and Additional Information: <br />f. ❑ Friable ❑ Non -Friable 9oth % Friable % Non -Friable <br />OPERATOR'S CERTIFI ATION: 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/placarded, and are in all respects in proper condition for transport according to applicable international and <br />national governmental regulations. <br />. Operator's Name and Title Print h. Si nature <br />L 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 12110 RETURN TO OPERATOR RS-F11A <br />