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Ow W REPUBLIC NON-HAZARDOUS SPECIAL WASTE Ili ASBESTOS MANIFEST <br /> 0 SERVICES <br /> If waste is asbestos waste,complete Sections I,ll,III and IV <br /> 3055469 <br /> If waste is NOT asbestos waste,complete Sections I,II and III <br /> I. GENERATOR (Generator completes la-r) <br /> eArt�il A6 hV�EPA ID Number a+ st Document Number 1.Page 1 of <br /> d.Generator's Name and Location: a.�?Cn tano(p- a �Aol �-m,t <br /> Stagg High School <br /> 1621 Brookside Road 1944 N.EI Pinal Drive <br /> Stockton,CA 95207 Stockton,CA 95205 <br /> f.Phone: (209)933-7045 x 2348 g Phone: (209)933-7045 x 2348 <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# 1F,Exp. Date I.Waste Shipping Name and m.Containers n.Total o.Unit <br /> Description No. Type Quantity. Wt/Vol <br /> 4204Y915040 06/17/18 Non-Friable Asbestos I C, -Z-5- <br /> GENERATOR'S <br /> Z-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 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 4he requirements of 40 CFR 268 and is np loo er a hazardous waste as defined by 40 CFR 261- <br /> Generator Authorized Agent Name Print . Signature r.Date <br /> ll. TRANSPORTER Generator completes Ila-b and Tracts orter cam letes lic-e <br /> a.Transportees Name and Address: <br /> Bowen Engineering and Environmental <br /> 4664 S.Cedar Avenue <br /> Fresno,CA 93725 } <br /> b.Phone: (559)233-7464 <br /> c.briver Name(Print) d.Si nature e.Date <br /> III. DESTINATION (Generator complete IBa-c and Destination Site completes Illd-g) <br /> qfnw <br /> DIS and Site Address: 0'A <br /> umber d. Discrepancy Indication Space: <br /> 91982-4298 <br /> v med material howbeen t d and to s knowledge the for oin • e aodurate. <br /> e- me of Au rized A ent Print f.Si Date <br /> IV. ASB STOS (Generator completes IVa-f and Ops or complete IVg-i) <br /> a.gpoeratoe Na e.and Ag tess: c.Responsible Agency Name and Address: <br /> Wen nglneenng an nv5: nmental San Joaquin Valley Unified Air Pollution Control District <br /> 4664 S.Cedar Avenue 4800 Enterprise Way <br /> Fresno,CA 93725 (559)233-7464 Modesto,CA 95356 <br /> b.Phone: d Phone: (209)557-6400 <br /> e. Special Handling Instructions and Additional Information: <br /> f.❑ Friable M Non-Friable ❑ Both %Friable %Non-Friable <br /> OPERATOR'S CERTIFICATI0N: 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/placatrded,and are in all respects in proper condition for transport according to applicable intemational and <br /> national governmental regulations.�✓ <br /> 9.O erat&s Name and Title Print natureDate <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 01114 DESTINAT40N RETURN RS-F11A <br />