Laserfiche WebLink
�A� REPUBLIC NON-HAZARDOUS SPECIAL WASTE & ASBESTOS MANIFEST <br /> SERVICES <br /> 11 If waste is asbestos waste,complete Sections I,II,III and IV <br /> i 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 b.Manifest Document Number c.Page 1 of <br /> NiA <br /> d.Gnerat a en Lloicr.lion:r ni t e.Generator's M in ddre <br /> 0l �brF <br /> 1:Ferr0ty?nzt <br /> -� East Ela-v ntfr Stleet 24692 Sorld Wedge Lane <br /> Tracy,CA WJ16 ti39�r}Crk-2133 Valencia.GA 91335 631-9114 X133 <br /> f.Phone: g. Phone: <br /> If owner of the generating facility differs from the generator,provide: <br /> h.Owner's Name: i.Owner's Phone No.: <br /> j.Waste Profile# k.Exp.Date I.Waste Shipping Name and m.Containers n.Total o.Unit <br /> Description No. Type Quantity Wt/Vol <br /> t'r!-.tt4141549r 10117014 <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 property described,classified and packaged, and Is in proper condition far trausporlalion 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.I certify and warrant that the waste has <br /> been treated In accordance with the requirements of 40 CFR 268 and is noy longer a hazardous waste as defined by 40 CFR 261. <br /> C R 1- <br /> p.Generator Authorized Agent Name(Print) q.Signature r.Date <br /> II. TRANSPORTER Generator completes Ila-b and Transporter completes 11c-e) <br /> a.Transporter's Name and Address;,._- t <br /> t��;lJl S-7= Fy 1- 1u,i l <br /> b.Phone: <br /> c.Driver Name Print d.Si nature" e.Date <br /> III. DESTINATION (Generator complete Illa-c and Destination Site completes Illd-g) <br /> a.Disposa�Facilit and Sjte Address: c.US EPA Number d. Discrepancy Indication Space: <br /> en;:aXJ Lan�;ni <br /> Manteca,CA 9533E <br /> b. <br /> I hereby certify that the above named material has bben abce t,d,andlto the.best,bf my Knpwled a the fore bin-is Xrue;altd a curate. <br /> e. Name of Authorized Agent(Print) I f Signature - `'` 1h.-PAte' <br /> IV. ASBESTOS (Generator completes IVa-f and Operator complete IVg-i) <br /> a.Operator's Name and Address: c.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 condRion for transport according to applicable internatlonal and <br /> national governmental regulations. <br /> q.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 01/14 RETURN TO OPERATOR RS-F1 1A <br />