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I L � <br /> i► ,� <br /> 64EP$!BB.00 NON-HAZARfa'OU.S•aRE+lilAL WASTE& ASBESTOS MANIFEST,) , <br /> y SERVICES <br /> .i. � crSeeions I,II,Iland IV V;seoM�let� 7 d <br /> tit� , <br /> GENERATOR (Generator completes is-r) _ <br /> a.Generator's US EPA,ID Number b.Mani f t Documel umber r.pogo 1 of <br /> NIP, m <br /> l d.Gsnerator'a Name and Location: a,Generators MailingAcress: <br /> .�rtt'•Vt:t�@}P.i11Sf1c• gf}�`1fi 4fFil0!1ithtx <br /> 7'i maft:tilt'n!rj <br /> llt,:krt, 1,'62,041,'62,04 ����r��r-�� <br /> f,Phone: CA g,Phone: <br /> If owner of ti?e generating facility diffels from the gonerator,provide: <br /> n,Owners Name: <br /> I.owners Phone No.: <br /> Waste Pf001e# k,Exp.Date . I.Waste'Shipping Name and .c❑ntainers n.Total o.Unit <br /> Desc' tion No. Type Quantity Wt-[Vo—.l <br /> -G-ENERATOK8 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 /> wasto in n treatment residue or a previously restricted hazardous waste subject to the Land Disposal Redriciion3-Feertify and warrant that the waste hoe <br /> been teo In actor. nce with tite requirements of 40 CFR 268 and is no longer a hazardous waste as darined by 40 CFR 261. <br /> p. ongtator Authorized <br /> Agent Name(Pril� Siiiature r-Date <br /> Ii. TRANSPORTER (Generator completes Ila-b and Transporter completes lilt,-e <br /> a.Trans orter's Name and d <br /> c, er Name ria 81 tufo`: e.Date <br /> Ill. DESTINATION (Generator,cornptotd`Illa-c and Destination Site completes Illd-g) <br /> a.Dispose-(acility nd sSite Address: e.US EPA Number d.Discrepancy Indication SPAM <br /> I otwafd endrin <br /> 9- S?3 &m tin Rd. <br /> A. <br /> 1 hereby cervi that'the above named material h an be m kdowled o for r ir,tru n9f z(QCt at <br /> e.Name of Authorized Agent Print _ __ _ Date <br /> IV. • ASBESTOS (Generator complete IVvt4 and.Operator- ' <br /> a.Operators Name and Address: o.Responsible Agency Name and.Address: <br /> b.Phone: d.Phone: <br /> e.SpeM1 Handling Instructions and Additional Information: <br /> f.❑ Friable ❑ Non-Frlabie 111 Bol h %,Friable %Non.PrIoble <br /> f OPERATOR'S CERTIFICATION:I hereby declare that the contents of this eonstgnment are fully and accurately described O)ove by the proper shipping pati% <br /> and aro clasnifled,packaged,mal'ked and labeled/placai0orl,and are in oil reapecta in proper condition for transport according to appiloahie international:and° <br /> notional governmental regulations. <br /> r g.Operator's Name and Title(Print) ahimI tate <br /> Operator refers to the company which owns,.leases,Operates,Controls,or supervises the farlllty belnyilemolishad or renovated,or the demolition or <br /> renovation aeration or both <br /> REV 07/14 RETURN TO PERATOR I23-Fr <br />