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RiF�l1M8ML/� NON-HAZARDOUS SPECIAL WASTE 8 ASBESTOS MANIFEST <br /> p Itwaste is asbestos waste,complete Sections 1,II,III and IV <br /> (� <br /> 314 2 c v 8 tf waste is NOT asbestos waste,complete Sections I,II.and III <br /> I, GENERATOR (Gene for completes la-r) 12473 <br /> % <br /> a.Genend s US EPA ID Number b.Manifest Document Number C.Page 1 of <br /> d.Generator's None and Location: e.Generators Mailing Address: <br /> iJ., .•I P��. :_=ic RµJ-.! road union Paci_ic Rc11 I ddl� <br /> H33 E. 41-h ST. 301 til; 2nd ACd.Attitrl: Taac9. Rrihdr_ <br /> Cy. 9520 , _n �c .slsi-idr4ar;d, OR97232 � ^re � , <br /> 53 <br /> If owner of the.genamting facility dHfem - the generator.provide: <br /> h. s Name: I.Owner's Phone No.: <br /> J.Waste Profile N k.Exp.Date I.Waste Shipping Name and M.Containers n.Total o.Unit <br /> Description No. Type Quantity Wt/Vol <br /> 0 1 i ii 3 ! 1/31/17 a <br /> GENERATOR'S CERTIFICATION: I he by 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, ssified and packaged,and is in proper condition for transportation according to applicable regulations;AND,if this <br /> waste is a treatment residue of previously restricted hazardous waste subject to the Land Disposal Restrictions.I certify and warrant that the waste has <br /> been treated in accordance with the requirements of 40 CFR 268 and Is no longer a hazardous waste as defined b 40 CFR 261. <br /> Ge eretor r4utltioriYed ant Name nt Sf nature r.bite <br /> 11. TRANSPORTER (Generator com Metes Ila-b and-Transporter completes Ilc-e _ <br /> a.Transporters Name and Address: li -__ _. <br /> ,nl.ed Ptitnp�:ig 51.1 VCr: s,c. <br /> 14000 E. Valle%r Blvd, <br /> Industry, CA. 9I;96 . , <br /> b.Phone' ti , <br /> c.Driver Name Pilot Id.Signature e.clate <br /> 111. DES ATION1 (Gene or complete Illa-c and Destination Site completes Illd-g) <br /> a:Diep�al q W s Site Address: c.US EPA Number d.Discrepancy Indication Space: <br /> VY !a1:c1 :.cal <br /> b. Z 95_:3 <br /> re that the aboW bomed mg terial has bKon ac ' ted nd to the of my knowledge the oing i •true and ecce te.' <br /> e. t nt a.Date/ / <br /> IV. ASBEST (Generator completes Na- and to -complete IVg-i) <br /> a.Operators Name and Address: c.Responsible Agency Name and Address: <br /> 8 2018 <br /> b.Phone: d.Phone: <br /> e.Special Handling Insbuctlons and Add I Information: <br /> H'ALTF <br /> f.❑ Friable ❑ Non-Friable Cl Bo %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 lotions. <br /> Operator's Name and Title Print h.Signature i.Date <br /> •Operator refers to the company which owns,leases,operates,controls,or supervises the facility being demolished or renovated,or the demolition or <br /> renovation operation or both <br /> REV 01/14 RETURN TO GENERATOR RS-F11A <br />