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REPUBLIC NO�HAZARDOWS SPECIAL WASTE& AESTOS MANIFEST <br /> i SERVICES '; t <br /> If waste,is asbestos:waste,complete Sections l 11,III and IV <br /> .'1314753 If waste is NOTasbestos waste;complete Sections i,,ll'and lll; fi <br /> t <br /> Ca 4;7 <br /> `GENERATOR (Generator•completes la-r) <br /> 'ba.Generator's US EPA ID Number b..Manifest Document Number. c.Page 16 <br /> WA <br /> -d.Gefierator s Name and,location: ..-•► . ,Z jy� e.Generators Mailing Address: <br /> f.Phone: <br /> If owner of the generating facility differs from the generator,provide: <br /> I <br /> h.Owner's Name: I.Owner's Phone No.: <br /> }Waste Profile# k.Exp.Date I.Waste Shipping Name and m.Containers n:Total .- o.Unit. <br /> Description No Type Quantity Wtfvol <br /> n <br /> GENEIRATOR"S CERTIRGATION_ t 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 for transportation according to applicable regulations;AND,if this <br /> was-been treated in is a ment residue of a previously restricted accordance with the rquiremelltsf 4tk Gardous ffi 26 ,anste ubbtec;to the L ©ispwdsteS defihed bly 40 t FR 26larrant Yiaat the.waste hash 3 <br /> p. Authorized Agent Name(Print) r.Date <br /> IL TRANSIPORTER Generator cam PIWlla-j and T s ort. om .etes,11c-e , <br /> a.Transporters Name and Address: <br /> ,lint Thorpe Oil ins <br /> PO.Box 3€ ; <br /> b.Phone:Lodi CA %241 -3 <br /> 4f (j <br /> a <br /> Al <br /> c.Driver Name Print s t+ `t d.Si nature e.Date KW <br /> III_ DESTINA FdiN (General complete'11ta-c and Destination Site completes Illd-g) <br /> a Disposal Fac&r.r and Site Address: e.US EPA Number d.Discrepancy Indication Space: <br /> 99W S.Rusin Rd / <br /> M�nleca CFi 9533�t � 4-��' <br /> hereby coirtify that the above named rnatenal fia'bee aces ted and to the be's of rif kn ed"e'the fore otn"is't curat .�^tij� <br /> e.Name of Authorized Agent Print f.Signature q.Date : <br /> IV. ASBESTOS (Generator complet - and Aerator fmplete IVg-i). <br /> a.Operator's Name and Address: .Responsible.AgencyName.and Address: r <br /> b.Phone: d.Phone:.. <br /> e.Special Handling Instructions and Additional Information: <br /> f.0 Friable 0Non-Friable El 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 /> 'i <br /> g. <br /> .O emtor's Name and Title. Print h.Si nature i.Date I <br /> *Operator refers-to the company which owns,leases,operates,controls,or supervises the facility being demolished or renovafed;orahe demolition or l <br /> renovation operation-or both J <br /> REV 12/10 RETURN TO OPERATOR Rs-FtrA <br /> . - - <br />