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WEAU0 IAC NON-HAZARDOUS SPECIAL WASTE & ASBESTOS MANIFEST <br /> t1►21 SERV.IC <br /> 1 If waste is asbestos waste,complete Sections I,II,III and IV <br /> If waste is NOT asbestos waste,complete Sections i,II and III <br /> 1. GENERATOR;(Generator completes la-0 . <br /> T— <br /> a.Generator's US EPA ID Ntimber', b.Manifest:Qocgmenf NOS r c.Page 1 of <br /> ' I�« <br /> d.Generator's Name and Location: _ e:Generators Mailing Address: <br /> d ill. ,C/�a lefl t) .f <br /> f.Phone: O �( j'- 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 WtNol <br /> q_�OL-1 y 13��q c7_7_/z— ll.,3s--- 70��3 <br /> F�. <br /> r <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.I 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 Print .Signature r.Date <br /> H. TRANSPORTER Generator completes Ila-b and Transporter completes 11c-e i <br /> a.Transporter'q.Name ai�a d Address: <br /> P.0 <br /> ifY'r f ttOfj.?ge5cg <br /> r_Wti,CA 4520 <br /> b.Phone: ` r' <br /> c.Driver Name Print d.Signature e. Date <br /> III. DESTINATION (Generafof complet Ille--o and Destination Site completes 111d-g) <br /> a.Disposal Facility and Site Address: c.US EPA Number d.Discrepancy Indication Space: <br /> F-ormfid%k1f'idR <br /> b. <br /> I hereby certify that the above named material has be n accepted and to the be`t of knowlecla the fore oin hsltrue'4 nd acc rate. <br /> e.Name of Authorized Agent Print Date <br /> IV. ASBESTOS (Generator corripl'tes IVa f dbpera�for complete IVg-i) <br /> a.Operator's Name and Address: t c.Responsible Agency Name and Address: <br /> b.Phone: <br /> d.Phone: <br /> e:Special Handling Instructions and Additional Infvl"mation: <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 /> g.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 12/10 GENERATOR RETAIN RS-F11A <br />