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l R'� REPUBLIC NON-HAZARDOUS SPECIAL WASTE & ASBESTOS MANIFEST <br /> 40*3 SERVICES <br /> -rw(C- <br /> 313 0 7 7 3 If waste is asbestos waste,complete Sections 1,It,til and IV 4- <br /> If waste is NOT asbestos waste,complete Sections I,11 and III <br /> GENERATOR (Generator completes la-r) <br /> a.Generator;sQUS EPA tD Number b.Manifest Document Number, iA C. Page 1 of � <br /> d. Generator's Name and Loca6an: ,yy e.Generator's t hai4ing yAddgmw. {{ <br /> -Jr-Li i&C' 5,&Col di.57, tc't- CT Ab. rn{fnf inn I L f 1 VL_ 'LOiJ lze11 <br /> NE a-rteca CA 95337 <br /> tri r� 53S& kiaddstnrte,9s 9s3sa <br /> f. Phone: K - 209-82S-13)700 <br /> �. �21JU, : Za-= 1 g. Phone: <br /> If owner of the generating facility differs from the generator, provide: <br /> k la.,teca 1Jn-F,iE-LJ School DiTtri�G 203-M-3�;L0 <br /> h.Owners Name: i. Owner's Phone No.: <br /> j.Waste Profile# k. Exp.Date 1.Waste Shipping Name and m.Containers n.Total o. Unit <br /> pp q 1 �L I <br /> Description No. Tye QuantityWt/Vol <br /> wig..ci(1C'119.1'�'� - ^LCISr,a�]:q.Z015 �, r!r:'l.y t3tC / IEsA <br /> 1 <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 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 accordancewith the requirements of 40 CFR 268 and is no longer a hazardous waste as defined by 40 CFR 261. <br /> k �� 1.;e- r- , <br /> enerator Authorized Agent Name Print q. Signature r. Date <br /> t.. TRANSPORTER Generator cam fetes Ila-b and Transporter completes lic-e <br /> a.Transporter's Name an�dy A�d}dress: <br /> Offtcr Oox1u5 ,. 1055 'x_ Emer2Id AVet-ILIP <br /> b. Phone: <br /> c.Driver Name Print l u e. Date <br /> III. DESTINATION (Generator compiet Ilia- and Destination Site completes Illd-g) <br /> a.Dis al Facility and Site Address: U EPA Number d. Discrepancy Indication Space: <br /> S7,1N ROAD-MA <br /> TVZti,CA?5 <br /> f <br /> fberebi certify Jhave named material has b A n acdepled st of my kpRwledge the reaojnq it true a4ralb. <br /> h. Na tho Agent Print t. a Dat <br /> I ASBE OS (Generator completes [Ga_1�5-56 Op4rator complete IVg-i) <br /> a. Operator's Name and Address: c. Responsible Agency Name and Address: <br /> >•.'ia':tdCi J r•?f;c�SC•`<;�ul <br /> Cost `a271 W Loulse Ave. <br /> 17i10 T`Ic,rr av Av, - M ante ca, CA 9533-6 <br /> h4antRca,CA 45".= Zia-E25aZC0 <br /> b. Phone*2n¢S`5 i`T d.Phone: <br /> e. Special Handling Instructions and Additional Information: <br /> L•cRut�'Cai.iaa is RcmC�-a Ci,rYL':�arlS�-�.kCa'.¢rr:¢nt:'C., Pry Ottlte39Y395b.MOdCSCc, CA 5S352,2V9-524-i11<is. <br /> f.El Friable Non-Friable El Both %Friable %Non-Friable <br /> OPERATOR'S CERTIFICATION: l hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name <br /> are classified,packaged, marked and labeled/placarded, and are in at respects in proper condition for transport according to applicable intemational and <br /> .oval governmental regulations. {J� <br /> ee /I I" <br /> g.Operator's Name and Title Print h. Signature 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 01114 DESTINATION RETURN RS-Fl 1A <br />