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REPUBLIC NON-HAZARDOUS SPECIAL WASTE tar ASBESTOS MANIFEST { <br /> I. SERVICES <br /> rr _, If waste is asbestos waste,complete Sections I,It,III and IV <br /> If waste is NOT asbestos waste,complete Sections I,If and Ili <br /> I I. GENERATOR (Generator completes la-r) <br /> Ia•Generators US EPA ID Number b.Manifest Document Numberc.Page 1 of <br /> wq <br /> d.Generator's Name and Location: e.Generator's Mailing Address: 1 <br /> .3hell Oil Products U-91 P0140701TR oohell r?d Pfoducts US <br /> 1267 N Country Club Blvd 6520 C•orporato Dn.fe <br /> f.Phone: Stooldon,CA K,204 925-967-0203 g.Phone: Iftdiinap lis,IN 46278 y26-967-02- I <br /> If owner of the generating facility differs from the generator,provide: I <br /> t h.Owner's Name: 1 1.Owner's Phdne No.: <br /> i.Waste Profile# k.Exp.Date I.Waste Shipping Name and m.Containers n.Total o.Unit I <br /> Description No. Type Quantity Wt/Voi <br /> �d"�rE J?01?�iCt rail <br /> � I <br /> GENERATOR'S CERTIFICATION: I-herehy certify that the above harKdd material is not a hazardous waste as defined by 40 CFR 261 or any applicable <br /> slate law,has been properly described,classified and packaged,and is In proper'condition for transportation.according to applicable regulations;AND,if this i <br /> waste Is a treatment residue of a previously restricted hazardous waste subject to.t6e Land Disposal Restrictions:l certify-arid warrant that the waste has <br /> been treated in accordance with the re uiremenfs.of 40 CFR 268 and is no Ion 6r a�azardous waste..as-deflnefl by 46 CFR 261. i <br /> 30 <br /> p.Generator Authorized Agent Name Print) 1 q.Sighatufe `� r.Date <br /> 11. TRANSPORTER Generator completes Ila-b and Transporter' coni letes Ilc-e <br /> a.Transpporter's Name and Address: 1 <br /> -P0 tJ U L Cy/-J 4/. i i-o n �-u��,-t 7-r, <br /> njc> 4 -Qjj <br /> b.Phone: %� )�/S 7`7J <br /> c.Driver Name Print _ d.Sip ure e.Date <br /> III. DESTINATION (Generator complete Ille-d and Destination Site completes tlld-g) <br /> a.Disposal Facility and Site Address: c.US EPA Number d.Discrepancy Indication Space: 1 <br /> Forward Landfill <br /> r <br /> 9--%9 S.Auetin Rd. <br /> b. Manteca.CA 06336 (W.C 24.1 U9. I <br /> I hereby certify that the above named material has been acce ed anti-to the best of-my knowledge the fore of true and accurate. I <br /> e.Name of Authorized Agent(P Int) f nature _ --rte i Date/ / r <br /> IV. ASBESTOS (Generator completes Ra--f and bfpieater-coKplete IVg-i) <br /> a.Operator's Name and Address: c.Responsible Agency Name and Address: <br /> b.Phone: d.Phone: MAR d Z015 <br /> .. <br /> e.Special Handling Instructions and Additional Information: <br /> CRA INC. <br /> 1NDIAVAP01 IS <br /> I <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/placarded,and are in all respects in proper condition for transport according to applicable international and <br /> national governmental regulations. <br /> 9.Operator's Name and Title Print 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 /> REV-01114 R�t URN TO GENERATOR RS-1711A <br />