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REPUELIC NON-HAZARDOUS SPECIAL WASTE & ASBESTOS MANIFEST <br /> SERVICES, INC. <br /> tf was!c is asbestos vraste,comp4cle Sections I,II,III and rV <br /> 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 i b.Man"est Dcament Number c.Page 1 of <br /> NIA <br /> d.Generator's Name and Location: e.Generator's Malkng Address: <br /> Paclfio West Petroleum.Inc Pacific West Petroleum Inc. <br /> 550 W Valpico Rd 550 W Valpioo Road <br /> Tracy,CA 95375 Tracy,CA 95376 <br /> f.Phonc:925-545-7910 P.Phone_:925.543-7910 <br /> If owner of the generating facility differs from the generetor,provide: <br /> h.Owner's Name 1.Oamer's Phore No.: <br /> J.Waste Profi'e 9 k.Exo.Date I.Wase Shippi:g Name and n:.Containers I n.Total o.Unit <br /> DesciPtion No. T ce i OuanMy WWoI <br /> 38501514430 C612612016 Fiberglass Slornge Tanis <br /> GENERATOR'S CERTIFICATION: I hereby certify that the above named materlal Is not a hazardous waste as defined by 40 CFR 251 or any applicallo <br /> slate law,has been properly described,classified and packaged,and is in proper condition for transportation according to appicab!e regulations:AND,if this <br /> waste is a treatment residue of a previous!y restricted hazardous waste subJoct to the Lard Disposal Rostr'cticns. I can:fy and warrant that the waste has <br /> been treated in accords co with the re ulrements of 40 CFR268 and is no loser a hazardous waste as defined by 40 CFR 61. <br /> Ger.erat uthorized A ent Name Print! I q.Signature, r.Date <br /> II. <br /> ThANSPORTER (Generator completes Ila-b a Transporter completes 11c-e) <br /> a.Transporter's Name and Address: <br /> b.Phone: L' ) - 15 <br /> c.Driver Name Print d.Signature I o.Date I <br /> III. DESTINATION (Generator complete Illa-c and Destination Site completes 111d-g) <br /> a.Disposal Facility and Site Address. c.US EPA Numbe: d.Discrepancy Indication Space: <br /> Vasco Rd.Landfill <br /> 40C1 N.Vasm Rd. <br /> Livermore.CA 94551 <br /> b.Phone:925.447-0491 <br /> herpy oetjfX that Aho above named material hos beeda ted and t the test o'm. kno+x!edoe the foregoing is true and aoc.,ra!e <br /> dyfa�� I 'S ' <br /> Narne of uthorized Agent Print f.Si5-n-7.fullb 1 0.Date <br /> IV. ASBESTOS (Generator completes IVa-f and Operator complete IVg-i) <br /> a.Operator's Name and Address: a Responsible Agency Name and Address: <br /> b.Phare: d.Phone: __ <br /> e.Special Handling Instruclians end Additional Informa5on: <br /> i <br /> f.U Friable Noe-Frlablc Both °;Friable %Non-F:iatle <br /> OPERATOR'S CERTIFICATION:I hereby decare that the con!ents of this consigrmonl are fully and accurately described above by ptope:shipping name <br /> and are classified,packed,marked and late:ed and aro!n a!I respells In proper corndbon for transport by highway according to applicab!e Internal onai and <br /> national governmental regulations. <br /> � I <br /> .Operator's Name and Title Print h.Si nature i.Dalc <br /> Operator refers to the company whic'i awns.leases,operates,cor.Ints,or supervises the facility being demol:shed or renovated,or tho demo:ition or <br /> renovalOn operation or both <br />