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�R� REPUBLIC NON-HAZARDOUS SPECIAL WASTE & ASBESTOS MANIFEST <br /> SERVICES <br /> 2843413 If waste is asbestos waste,complete Sections I,II, III and IV <br /> If waste is NOT asbestos waste,complete Sections I, II and III <br /> I. GENERATOR (Generator completes la-r) <br /> eAGtrffidZ�iJ.S EPA ID N�imber 1204flest <br /> Document Number 1 c.Page 1 of <br /> d. Generator's Name and Location: a <br /> Stagg High School 1944 N.El Pinal Drive <br /> 1621 Brookside Road <br /> Stockton,CA 95207 Stockton,CA 95205 <br /> 3 O . Phone: (209)933-7045 x 2348 <br /> f. Phone: <br /> If owner of the generating facility differs from the generator, provide: <br /> h.Owner's Name: i.Owner's Phone No.: <br /> j.Waste Profile# k.Exp.Date I.Waste Shipping Name and m.Containers n.Total o.Unit <br /> Description No. Tyee _q229by WtIvol <br /> 4204Y915040 Non-Friable Non-Friable Asbestos 3 <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 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 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 is no longer a hazardous waste as defined by 40 CFR 261. <br /> /'Lie 1 <br /> p. Generator Authorized A ent Name (print) q.Si nature r.Date <br /> Il. TRANSPORTER Generator cam fetes Ila-h and Tlans ❑iter cam fetes Ilo-e <br /> a.Transporter's Name and Address: <br /> Bcwca Engincenrig and Envhonm,anal <br /> 4664 S.Cedar Avenue <br /> Fresno.CA 93725 <br /> b. Phone: (559)233-7464 <br /> c.Driver Name Print i ature e.Date <br /> III. DESTINATION (Generator comptete Illa-c and Destination Site completes Illd-g) <br /> a. CFis osal Facility and Site Address: C.US EPA Number d.Discrepancy Indication Space: <br /> Forward Landfill <br /> 9999 Austin oad <br /> Manteca,C X36 <br /> 09)982-4298 <br /> b. <br /> I here c rti th ove named material has n cc e ed and to the h, I is true opol apeVrate. <br /> 21, <br /> e.Nlame of A I ed A t Pri t. n . Dat <br /> IV. TOS erato compl S I f and OWMItor co le IVg-i) <br /> a.$peratoCs Name.and A00ress= I c.Responsible Agency Name and Address: <br /> ower Engineenng and Environmental San Joaquin Valley Unified Air Pollution Control District <br /> 4664 S.Cedar Avenue 4800 Enterprise Way <br /> Fresno,CA 93725 (559)233-7464 d.Phone: (2Modesto:CA 953(2 <br /> 09)ss7557-6400b. Phone: <br /> e. Special Handling Instructions and Additional Information; <br /> log <br /> L EJ Friable 6 Non-Friable 0 Both %Friable %Nan-Frfabfe <br /> OPERATOR'S CERTIFICATION: I hereby declare that the contents of ttais 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 regull-a��tioon',ss.'�� <br /> O eratorsNand Title Print h. 1 not a 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 DESTINATION RETURN Rs-F11) <br />