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REPUBLIC NON-HAZARDOUS SPECIAL WASTE & ASBESTOS M IF`°11 T <br /> 1:6 SERVICES <br /> If waste is asbestos waste,complete Sections I,II,Ill:and IV <br /> 1314754 <br /> If waste is.NOT asbestos waste,complete Sections I,11 and,lll <br /> d <br /> - � 7 <br /> I. GENERATOR (Generator.completes la-r) ' <br /> a.Generator's US EPA ID Number b.Manifest Document Number, c.Pages'Of <br /> WA <br /> d.Generator's Name and Locationz e.Generator's Mail'ng Address: <br /> - IrL 00�� <br /> f.Phone: <br /> .. X g;_'Phone <br /> m ..,. <br /> If owner of lh6'generating facility differs from the generator,provide: <br /> h.Owner's Name: 1,i.Owner's Phone No.:" <br /> j,Waste Profile.# k.Exp.Date: I.Waste Shipping Name and' m.Containers <br /> n.Total o.Unit <br /> Description _" No.. Typ <br /> e uanti WtfVol <br /> &7 411# <br /> j{6 <br /> C I <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 w e ubject.t the Land.Disposal Restrictions:I certify.and warrant that the.waste'has <br /> '.been treated in accordance with the requirements of 40 CFR 268 a i n to " ous waste as defined by CFR261. <br /> 47 71149�f <br /> enerator Authorized Agent:Name.(Print, nafu r.Date, _ <br /> ;. _" _ " <br /> 11: TRANSPOE2TER Generator corn let Ila- and lanspoyer completes II'c-e <br /> a.Transporter's Name and Address: <br /> Jim Thorlse OitJtic. <br /> Ro awx V {{ <br /> b.Phone:W,CA 0249 ZQflv3 $I / <br /> I <br /> `i <br /> c.Driver Name Print Si nature,, Dat <br /> e. e ` <br /> 111. DESTIN ION Generator corn tete Ills-c and Destination Si <br /> _..._ _.. <br /> ( p to completes Ilid-g) <br /> "ja.Disposal Facility and Site Address: c:US EPA Number d.Discrepancy Indication Space t U Ei' <br /> I M <br /> g Aust Rd. <br /> tkinteaa,CAb. <br /> _.,. v <br /> een acce ted and to the-best of.m knowled a the fore oin is`tru Sa cdorate.. 1 <br /> hereb cern that ttie'above named material has F A " <br /> e.Name:of Authorized Agent Print f."S-tare q.Date " <br /> IV. ASBESTOS (Generator completes IVa-f and Operator complete IVg-i) f� <br /> a.Operator's Name and Address: c Responsible Agency Name"'and Address: ! <br /> b.Phone: { <br /> d.Phone: <br /> e.Special Handling Instructions and Additional Information: <br /> f.1.Friable ❑ Non-Friable O-Both %Friable %'Non-Frjable: 1 <br /> OPERATOR'S CERTIFICATION:1 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 /> O orator`s Naine'and.Titie Print h.Signature, <br /> a.Date <br /> r <br /> Operatorrefersto the company whichowns,leases operates,controls orsupervises.the facility being demolished or renovated,or the demolition or,enovation operation or both <br /> REV.12H0 RETURN TO OPERATOR .. Rs-Fva <br /> x <br />