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F BLOC NON -HAZARDOUS SPECIAL WASTE & ASBESTOS MANIFEST If waste is asbestos waste, complete Sections 1, II, III and IV 3142238 if waste is NOT asbestos waste, pomplete Sections I, 11 and I It 1. GENERATOR (Genera r completes la-rl P t a n -t a. Generate US EPA ID Number anitlSka Address: b. Manifest Document Number a Page 1 or d. Generators Nene and Location: Lal d• 111 e. Generator's Mailing Address: Unica l Pz�-J fic R:t�. !_ 'o -� Lnlui) Paci!'ic Railroad 833 E. Rth ST. i. Date 301 ENE Ind Avd.Atitn: ^sa.;ci I::,hde t� :,...t f.Ptibr�e: 'tc+'n, CA. 9520 �., - _n d, OR If owner of the:generating facility dlffers the generator. provide: h. Owners Name: re ce that ftrial has Wen accept6dtnd to the -AW of W knowledge the foregoing IV.truO and ,bccu te.' i. Owners Phone No.: J. Waste Profile # It. 8.0- 0 W-1 I. Waste Shipping Name and m. Containers n. Total o. Unit No. Type n Quantity WWoi 4_041717937 1-1/31/17 ENVIRONMEN GENERATOR'S CERTIFICATION: I hert by certJfy that the above named material is not a hazardous waste as defined by 40 CFR 261 or any applicable state law, has been property described, r4.sstW and packaged, and is in proper condition for transportation according to applicable regulations; AND, if this waste Is a treatment residue of prevjou ly restricted hazardous waste subject to the lend Disposal Restrictions. I certify and warrant that the waste has been treated in accordance with the requ ments of 40 CFR 268 and no lodger a hazardous waste as defined b 40 CFR 261. p. Ga orator Authorized rit N I q. Signature r. . to He -- - I KPJIJDrVK I CK uen lot' cam leges Ila -a drlu I RU M R"I wrn rn►na "Lo—w). a. Transporters Name and Address: tint] ted Pump --':)g Services, inc. 14000 E. Valle- 131vd. - Industry, CA. �,I, ^161-:^„ I1; ; _r)n )r c. Driver Name Print 'd. Signabn ' e. uaw III 111MCTIMATInI I U'Zonarninr etmmnlata Illswr- and t=laatlnatinn SItA rbmnlates 111d -al a: Disposal'kaGiRy anitlSka Address: US EPA Numtier d. Dlstrepancy Indication Specs: r�ard Lal d• 111 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 ilabeledlplacarded, and are In all respects In proper condition for transport according to applicable international and / SrE—ZN�n Rd. a. tors Name and Title Print h. Signature i. Date •Operator refers to the company which ow0s, leases, operates, controls, or supervises the facility being demolished or renovated, or the demolition or renovation operation or both b. re ce that ftrial has Wen accept6dtnd to the -AW of W knowledge the foregoing IV.truO and ,bccu te.' e, t nt IV eSRFSTn-q lranamtnr ✓Y nnnlAtA.4 [Va-f and OnsMtnt-mmnlete IVA-tl a. Operators Name and Address: c. Responsible Agency Name and Address: b. Phone: d. Phone: e. Special Handling Instructions and Addr Information: t. ❑ Friable ❑ Non -Friable ❑ Both J % 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 ilabeledlplacarded, and are In all respects In proper condition for transport according to applicable international and nationalgovernments] regulations. a. tors Name and Title Print h. Signature i. Date •Operator refers to the company which ow0s, leases, operates, controls, or supervises the facility being demolished or renovated, or the demolition or renovation operation or both REV 01114 RETURN TO GENERATOR as-r11A