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REPUBLIC" NON-HAZARDOUS SPECIAL WASTE & ASBESTOS MANIFEST i <br /> SERVICES <br /> 40+4 <br /> If waste is asbestos waste,complete Sections I,11,Ilk and IV <br /> 5520656 If wasle.!s NOT ar4estos waste,complete Sections I,II and III <br /> I. GENERATOR (Generator completes la-r) <br /> a.Generator's US EPA ID Number b.Manifest Document Number c.Page 1 of <br /> d. Genera(�8N V l Nfff iy I JJ Comprally Inc) e.Generator's Mallin iner, nc.{Formally BJJ Company Inc) <br /> 2341 E. Maripos`a Rd. IP-.O.Sox 30010 <br /> f. Phone: g.Phone: <br /> Stockton CA 95205 209-941-8W1 Stockton,CA 95213 209.941.8361 <br /> If owner of the generating facility differs from the generator,provide: <br /> h.Owner's Name: I i. Owner's Phone No.: <br /> j Waste Profile# k. Exp.Date 1.Waste Shipping Name and m.Containers 1 n.Total o Unit <br /> Description No. Type Quantic wt/Vol <br /> ( GM � " Y <br /> GENERATOR'S CERTIFICATION: I hereby 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 properly described,classified and packaged,and Is In proper condition for transportation according to applicablo regulations;AND,If this <br /> waste is a treatment residue of a 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 Iwo longer a hazardous waste as defined by 40 CFR 261. <br /> Generator Authorized Agent Name(Print) <br /> il. TRANSPORTER Generator completes Ila-b and Transporter completes lic-e <br /> a.Transportar's Name and Address: <br /> L ct ( WrA S T-f— <br /> b. Phone: <br /> e .� -7-7 <br /> c.Qrive ame Print d.Si natur e.Date <br /> Ill. DESTINATION (Generator complete lila-c and Destination Site completes 111d-g) <br /> a. Disposal Facility and Site Address: c. US EPA Number d.Discrepancy Indication Space: <br /> rorwd Landfill <br /> 9999 3.Austin Rd. <br /> b. <br /> I hereby ce ad material h e d and to the best of my knowledge the fore oin is true and accurate. <br /> a.Name of Autho zed A enETint ature .Date <br /> IV. ASBESTOS (Generator completes lVa-f A Operator complete lVg-i) <br /> a.Operator's Name and Address; c.Responsible Agency Name and Address: <br /> b. Phone: d.Phone: <br /> e.Special Handling instructions and Additional Information: <br /> f.0 Friable EJ Non-Friable 0 Both %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 /> natlonal governme t I re ulations. <br /> O erator's Name and Title Print h,Si na re i.Qete <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 0lf14 DESTINATION RETURN RS-F11A <br />