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i t 1 .1 v to REPUBLIC NCOHAZARDOUS SPECIAL WASTE 'ASBESTOS MANIFEST SERVICES O C T 2 2 2014 r 1916962 �C'6 2 If waste is asbestos waste,complete Sections I,II,III and IV ..i If waste is NOT asbestos waste,complete Sections I,II and III ENVIRONMENTAL HEALTF- I. GENERATOR (Generator completes la-r) DEPARTMENT a.GeneratKl.s US EPA ID Number b. Manifest Document Number c.Page 1 of 11 d.GenerattraA%Tnpy�.om�Y R pt e.Generator's M�i q Ac e :ev ng Ffltriity Trutt East Eleventh Street 24692 Sand Wedge Lane Tracy,CA 95376 861-904-2133 Valencia,CA 91335 681-904-2133 f. Phone: g. Phone: If owner of the generating facility differs from the generator, provide: h.Owner's Name: i.Owner's Phone No.: j.Waste Profile# k. Exp. Date I.Waste Shipping Name and m. Containers n.Total o. Unit Description No. Type Quantity WtfVol 42041416497 10/17014 Soil t J C.Y 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 state law,has been properly described,classified and packaged, and is in proper condition for transportation according to applicable regulations;AND,if this waste is a treatment residue of a previously restricted hazardous waste subject to the Land Disposal Restrictions. I certify and warrant that the waste has been treated in accordance with the requirements of 40 CFR 268 and is no longer a hazardo``u''s�wasste as defined by 40 CFR 261. p. Generator Authorized Agent Name(Print) q. Signature r. Date II. TRANSPORTER Generator completes Ila-b and Transporter completes Ilc-e a.Transporters Name�-7 Address- VAL b. Phone: C t L/e:W Y—\ c.Driver Name Print d. Signatur(:;4 e.Date III. DESTINATION (Generator complete Illa-c and Destination Site completes Illd-g) a. DisposalFFlitdandntlg Address: c. US EPA Number d. Discrepancy Indication Space: 9999S.Austin Rd. Manteca,CA 95336 20a ?4 b. I hereby certify that the above named material has bben a c Ot darrcqto the?best f,my Howled a the fore in is ue;afid curate. e. Name of Authorized Agent Print .Si n ure 9.D to IV. ASBESTOS (Generator completes IVa-f and Operator complete IVg-i) a.Operator's Name and Address: c. Responsible Agency Name and Address: b. Phone: d. Phone: e. Special Handling Instructions and Additional Information: f.❑ Friable ❑ Non-Friable ❑ Both %Friable %Non-Friable OPERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name and are classified, packaged,marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations. Orato 'e rator's Name and Title Print h. Signature i.Date *Oper refers to the company which owns,leases,operates,controls,or supervises the facility being demolished or renovated,or the demolition or renovation operation or both REV 01/14 RETURN TO OPERATOR RS-F11A