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REPUBLIC NOeHAZARDOUS SPECIAL WASTE & ASBESTOS MANIFEST <br /> s,>:az►rces <br /> • r� n Ir waste is asbestos waste,oomptete:t3ecCions{,il,ttl grid N <br /> 14 2 7 0 9 O If waste is0T asbestos waste,complete Sections 1,tt and Iii <br /> 1. GENERATOR (Generator completes la-r) <br /> a.Generator's US EPA ID Number b:Manifest Dodi lent Number C.Page 1 of <br /> NIA <br /> d.Gene Name Location: a.Generator's Marlin Tess <br /> It ralitar, Inc, UlHatner,lnc. <br /> 3440 E.Main St. 10M Waslrrtoor .Dr.Ste apo . ... <br /> Stockton,CA M06 3W703t19 i Westminster.CO 80021 303 II&M1 <br /> f.Phone: g.Phone: <br /> if owner of the generating facility differs from the generator,provide: <br /> h.Own"Name: :. i.O~s;Phone No:: <br /> J Waste Profits# k.Exp,Date 1.Waste Shipping Name and m.Cotdainers w Total o.Unit <br /> Description No` Quenft W Wal <br /> 420044883 3/14/2015 Soil with Debris pt?a 04.: 0a_0 CY <br /> GENERATOR'S CERTIFICATION: I hereby certify that the above named rnateriat is not a hazardous waste as defined by 40 CFR 267or any applicable <br /> state law,has been properly-described,classified and packaged,and-19 In pmpa<condition for transportation arxording to:appricable regulations;AND,if this <br /> waste is a treatment residue of a previously restricted hazardous waste subject to th ad Disposal Restrictions.I certify and warrant that the waste has <br /> been treated in accordance with the 2Lu <br /> Mients 2� CFR 288 and is nolo waste as defrned b 40 OFR tel. <br /> 71 <br /> .adheralor Authorized A Brit Name(Print) . <br /> e <br /> r_ <br /> 11. TRANSPORTER Generator completes lla-b and Transporter completes 11c-e <br /> a.Transporter's Name and Address - <br /> L,0 7224 tie s.aoo-i-w LLQ OreRctr C� . <br /> c.Driver Name Print d.SiansLWW7 e.iia . ... . <br /> In. DESTINATION (Generator complete 1116we and Destination Slte completes 111d-g) <br /> a.Disposal Facift and Site Address: &US EPA Number d..Discrepancy Indication Space: <br /> l=otiva+d t_aricifilt - <br /> SM S.Austin Rd <br /> ti- <br /> Manteca,CA 95336 209-9824296 <br /> rothalitho above namJTd hmterial has been a and to lh*J*Rofmv kn fa" true <br /> e. 910 Ajlhoftedent tint f.sI na e <br /> 1V. ASBESTOS (Generator completes lVa f'and Operator complete IVg-i) <br /> a.Operator's Name and Address: c.Responsible Agency Name and Address: <br /> b.Phone. d.Phone <br /> a.Special dandling Instructions and Additional Information: <br /> LO Friable El N n Friable [I Both 96 Friable °Ao Non-F'a Ie <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 iabeledlptacarded.and are In all respects in proper condition for transport according to apppeable International and <br /> national dwernmentel re ulations.. <br /> 0. <br /> tor&Name and Title Print h.Sl #urs 1 <br /> *Operator refers to the company which owns,leases;.operates,con troIs,or supervises t atrllity being detrto� orfEnOVa ,ar Nie demolt4on ... <br /> renovation operation or both <br /> -REV 12110 .:.::;DESTIN.ATION RETURN RS-F11A <br />