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�x�RA REPUBLIC NOW-HAZARDOUS SPECIAL WASTE & ASBESTOS MANIFEST <br /> SERVICES <br /> i <br /> 3 i O 7 If waste is asbestos waste,complete Sections I, 11,III and IV <br /> If waste is NOT asbestos waste,complete Sections I,II and III <br /> GENERATOR (Generator completes,la-r) <br /> _. generat�or's US EPA ID Number b. Manifest Document Numberhl:Fc <br /> C Page 1 of <br /> : . . <br /> d.Generator's Name and Location: e. Generator's Mailing Address: <br /> Marteca Unified School district/E-Anzimmant fn. 2272 W. Louise Ave. <br /> 1700 Thomas Ave; -aa-— - Mar,*eca CA 95337 <br /> 209-523- 200 <br /> f. Phone: .- . Phone: <br /> If owner of the generating facility differs from the generator,provide: <br /> h. Owner's Name: Manteca Uri'fied a:l"eol "-I-trict i. Owner's Phone No.: 20--$-2S-a-200 <br /> j.Waste Profile ii k.Exp.Date t.Waste Shipping Name and m. Containers n.Total o. Unit <br /> Description No. Type Quantity WWol <br /> '�20a101867t. Cctct:nris,at?z5 t vrr 'iai�l? 1 5A / Y^ <br /> G <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 266 and is no longer a hazardous waste as defined by 40 CFR 261. <br /> ,•ie- --L r--- - /3- <br /> Generator Authorized A ent Name Print .Signature r. Date <br /> TRANSPORTER Generator completes Ila-b and Transporter completes lic-e <br /> ransporter's Name and Address: <br /> Past W4Ce -R?x 3g58. 2055 N Emerald Avenue <br /> Wodestc,.CA 95252' <br /> b. Phone: <br /> c, Driver Name(Print) d.SI n e. Date <br /> III. DESTINATION (Generator complete Illa-c and Destination Site completes 111d-g) <br /> a. Disposal Facility and Site Address: c.US EFTA Number d.Discrepancy Indication Space: <br /> �9- s.AU3TIi FG'jEG�,rv11:f1TE'F, }.9-33 :A aec. <br /> b. <br /> I 11erebAoertV th tk aVov4 named material has tree cce ted arAAo th t my knowled a the foregoing is true a a <br /> "'— I <br /> I - t I/ �I I � I\' 1 14) J � <br /> e. amt, Authorized t I f. nature . Date <br /> IV. ASBEST (G nerator completes I d ator plete IVg-i) <br /> a.Operator's Name and ess: c. Responsible Agency Name and Address: <br /> 'mar,,wa urrinad sc-lc.1 r.-.1_t 2771,W.l aulee.Iva. <br /> 17007ham2sAYG. i!'artcc;,CA SS-335 <br /> M;intaca,CA 9533E 294-E2S-3190 <br /> b.Phone:U'°-R2`- 2V'7 d. Phone: <br /> e.Special Handling instructions and Additional Information: <br /> _wn0tbreaktaa¢s, ^ama..lCJantr.-.cr E- Atztimr-nt.inC.,PostC3i�._.BOY S9:-Z.VCai.sta. CA 33=52,ZC9-Sea-0611 =7.T.J05 NUMK;i-17-1SCI <br /> f.❑ Friable)C] Non-Friable I] Both %Friable 100 % 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 la beledlplacarded,and are in all respects in proper condition for transport according to applicable intemational and <br /> final govemmental regulations. <br /> q.Operator's Name and Title P nt h. Si nature 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 /> -enovation operation or both <br /> 1114 DESTINATION RETURN <br /> RSFt 1 A <br />