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c REPUBLIC NON--HAZARDOUS SPECIAL.WASTE & SA BESTOS MANiFEST SEMI"S '�!L l U H H If waste€s asbestos waste,complete Sections 1,it,III and IV €f waste is NOT asbestos waste,complete Sections I,11 and III I. GENERATOR (Generator completes la-r) a.Generator's US EPA ID Number b.Manifest Document Nurnbar T7--P-Ge,1'of WA d.Generators Name and Location: a.C3enerator's Mailing A dress Ufflalltl3r, Inc. .1.11ft er,Inc. 3440 E Mein St J=5 Wettmoar t?r.Sfa 400 f.Phone: ft*=.OSA 05MS Phone: Westminsiff,CO 8W1 303- 79-30$1 If owner of the generating facility differs from the generator,provide: h.Owner's Name: i.Owner's Phone No.: I.Waste Profile# 1' Exp:Date 1.Waste Shipping Name and mars n.Total o Unit Descripifion No: Type Quan VA/Vol 4M4144893 31141 015 Sail with Debris CY GENERATORS CERTIFICATION, I hereby certify that the above named material is not a hazardous waste as defined by 40 CFR 261 or any applicable state low,has bean properly described,etassilled and packaged,and Is In proper condition for transportation according to applicable regulations:AND,if this waste is a treatment residue of a previously restricted hazardous Waste subject to tya Land Disposa€Restrictions.t certify and warrant that the waste has been treated.in accordance with the requirements of 90 CFR 268 and is no lonjWr a o waste as defined 4D CFR M. pGeheralor Authorized Agerit Name (Pr' 4Q. a I r.Qate IL TRANSPORTER Generator completes Ila-b and Transporter completes IIC-e a.Trunsporter's Name and Address: Lb l t?r Le Yf l- Grl� b.Ph na v t I Uodiiiama(Print) d.Si nature e.Date ill. DESTINATION (Generator complete Ma-c and Destination Site completes Itld-g) e.Dlsposalfacr111,y and Si a Address: c.US EPA Number d.aisorepartcy Indication Spars: r,�I�tI L�IdiE� ,. 9M S.Austin Rd. b. Manteca,CA 95338: 2"82-0 1 herellf ceift that the above named material has ee acce d t 8 40*"fAmy 4fknowledge the foregoing trugiand acOuratdd, e.Name of Authorized Agent tint f .Date IV. ASBESTOS (Generator completesan&grrperpfbr complete IV94) a.Operator's Name and Address: rH Respeitsible Agency Name and Address: b. one: d.Phone: e:Sp eclat Handling Instructions and Additional Information: E 0 Friable 13 Non-Friable ❑ Both %Friable %Non-FrIable OPERATOR'S CERTIFICATION:I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name and are classified,packaged,marked and fabeledlplacarded,and are in aN respects in proper condition for transport according to applicable international and national goverrimental regulations. a.O tors Name and Title Forint h.Si attire f.Date "Operator refers to the company which owns,leases,operates,controls,or supervises the facility being demolished or renovated,or the demolition or renovation operation or both REV 12rlo DESTINATION RETURN Rs.rIIA