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R7�REPUBLIC NON NZARDOUS SPECIAL WASTE & - IBESTOS MANIFEST <br /> �fy2� SERVICES \.i/ N"1011 <br /> 0 5 5 9 6 6 If waste is asbestos waste,complete Sections 1..11,111 and IV <br /> If waste is NOT asbestos waste,complete Sections I,11 and III <br /> I. GENERATOR (Generator completes la-r) <br /> a.Generator's US EPA ID Number b. Manifest Document Number c. Page 1 of <br /> d.Generator 's Name and Location: e.Generator's Mailing Address: <br /> Den's Auto Den's lotto <br /> 308 South Et Dorado 626 East Galin Rd <br /> f.PhoJtockton.CA 95203 209-462-1282 g.Phone: Stockton,CA 95231 209-4624267 <br /> If owner of the generating facility differs from the generator,provide: <br /> h.Owner's Name: i.Owners Phone No.: <br /> j.Waste Profile# k.Exp. Date 1.Waste Shipping Name and m.Containers I n.Total o.Unit <br /> Description No. Type Quantity WI/Vol <br /> 4204139473 6/6/2014 Soil 90 (D Y1 Ds <br /> CY <br /> B. <br /> C. <br /> GENERATOR'S CERTIFICATION: I hereby certify that the above named material 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 proper condition for transportation according to applicable regulations;AND,if this <br /> waste is a treatment residue of a previously restricted hazardous waste subject to the Land Disposal Restrictions.1 certify and warrant that the waste has <br /> been treated in accordance with the requirements of 40 CFR 268 and is no longer a hazardous waste as defined by 40 CFR 261. <br /> p.Generator Authorized Agent Name Printf I q.Signature r.Date <br /> II. TRANSPORTER Generator completes Ila-b and Transporter completes Ilc-e <br /> a.Trans o erNgme and Address: <br /> ContainerDeb <br /> 1145 W.Charter Way <br /> b.Phone tockton,CA 95208 <br /> c.Driver Name Print d. nature e.Date <br /> III. DESTINATION (Generator comple Illa-c and Destination Site completes Illd-g) <br /> a.Disposal Facility and Site Address: C.US EPA Number d.Discrepancy Indication Space: <br /> Forward Landfill <br /> 9999 S.Austin Rd. <br /> b. Manteca,CA 95336 201}982 298 <br /> I hereby certify that the above named material has b4en ac(feptefj and tote 4est Af my knowledge the foregoiho is trGe add ccur te.Ij <br /> e.Name of Authorized Agent Print f. i natu a <br /> IV. ASBESTOS (Generator completesIV-51 and Oper or complete IVg-i) <br /> a.Operator's Name and Address: G.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/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 12110 DESTINATION RETURN RS-F11A <br />