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XF-08LIC NON -HAZARDOUS_ SPECIAL WASTE & ASBESTOS MANIFEST <br />314 2 �' 8 If waste is asbestos waste, complete Sections 1,11,111 and IV <br />L u If waste is NOT asbestos waste, complete Sections I, II and III <br />I. GENERATOR (Gene tnr rnmoletes la -r) c.*v _c. T -: A7 7 <br />a. Generator's US EPA ID Number <br />c• US EPA Number <br />b. Manifest Document Number <br />c. Page 1 of <br />d. Generator's Nate and Locabon.: <br />i <br />e. Generator's Mailing Address: <br />Union Po"'. `ic R;.;. !_ <br />o :c: <br />Union Paci l is Railroad <br />833 E. q" Ch S`i'. <br />201 NE 2nd Avd.Attii: Taaci Rohde <br />t QVC!'too, Cli. 95:'0 <br />. - <br />:s.cl, OR 97232 <br />�. <br />r <br />g'� 7r. 1 <br />if owner of tt►e.generadng facility differs from <br />the generator, provide: <br />h. Owner's Name: <br />i <br />i. Owner's Phone No.: <br />J. Waste Profile # <br />It. Exp. Date_ <br />I. Waste Shipping Name and <br />m. Containers <br />n. Total <br />o. Unit <br />No. <br />Type <br />Description <br />Quantity <br />WI/Vol <br />04,i;ii931 <br />DEC� 2 Q ZOIi <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, classified and packaged, and is in proper condition for transportation according to applicable regulations; AND, if this <br />waste is a treatment residue of restricted hazardous waste subject to the Land Disposal Restrictions. I certify and warrant that the waste has <br />been treated in accordanments of 40 CFR 268 and no Ion a hazardous waste as defined b 40 CFR 261. <br />p. Ge orator Authorized <br />4. Signature <br />r. <br />a. Transporters Name and Address: t?„yLeci PU'tPi:)Cj Sul V1C.,Lar inc. <br />14 000 E. Va l leer Blvd. <br />Industry, CA. 9171426 ,,, <br />b. Phone: 6 a a <br />r / P, A / 11-111--A 1r- 11 it /- r1 <br />III_ DESTINATIAIM M'AnarsdInr mmnlAtA Ilia -t: and ❑Astination Site rmmnlates IIId-o). <br />citify andStte Address: <br />a. DTinec <br />c• US EPA Number <br />d. DIS&6pancy Indication Space: <br />cl L4i�dlill_ <br />wW Information: <br />i <br />% Friable % Non -Friable <br />OPERATOR'S CERTIFICATION: I hereby <br />and are classified, packaged, marked and <br />national governmental regulations. <br />declare that the contents of this consignment are fully and accurately described above by the proper shipping name <br />placarded, and are In all respects In proper condition for transport according to appllcable International and <br />b. <br />h. Signature <br />i. Date <br />re . ;ce that Me aboW uned matorial has blien ac ted nd to the best of my knowiedge the to oing i tru# and Accu te.' <br />e. NhtW19A&qVA faint I IrIntl <br />i <br />Date/ J <br />IV. ASBESTOS (Generator oompletes IVa --f and OpgrAtoftomplete IVg-1) <br />a. Operators Name and Address: <br />b. Phone: <br />c. Responsible Agency Name and Address: <br />d. Phone: <br />e. Special Handling In ns and Addhk <br />wW Information: <br />f. Cl Friable O Non -Friable O Both <br />% Friable % Non -Friable <br />OPERATOR'S CERTIFICATION: I hereby <br />and are classified, packaged, marked and <br />national governmental regulations. <br />declare that the contents of this consignment are fully and accurately described above by the proper shipping name <br />placarded, and are In all respects In proper condition for transport according to appllcable International and <br />Q. Operator's Name and Title Print <br />h. Signature <br />i. Date <br />*Operator refers to the company which a”, leases, operates, controls, or supervises ft facility being demolished or renovated, or the demolition or <br />renovation operation or both :J <br />REV 01114 1 <br />RETURN TO GENERATOR RS-F11A <br />