Laserfiche WebLink
+� 721 REPUBLIC NON-HAZARDOUS SPECIAL WASTE & ASBESTOS MANIFEST <br /> �� SERVICES r ro( <br /> 3130776 <br /> ] 11 O '�] If waste is asbestos waste,complete Sections I,II, III and IV <br /> J f If waste is NOT asbestos waste,complete Sections I, 11 and III <br /> GENERATOR (Generator completes la-r) <br /> a.Generators US EPA ID Number b.Manifest Document Number 4 c. Page 1 of <br /> d.Generators Name and Location: e.Generator's Mailing Address: <br /> .€wr"cw r't't,�i:SC1100' r ___ :- �TAGitGr'R�tlnC -�71 W 'Auise Ave. <br /> -=_:i ,CA 3533' <br /> f. Phone: . -- :..5-�24-= g. Phone: <br /> If owner of the generating facility differs from the generator, provide: <br /> h.Owner's Name: Mai,-era 4-ji-r Sc`oo l �` `- 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. Type Quan' WtfVol <br /> =�:� ��'•i TC�t7 _..__: _c 2{.a FL's _ ,_ -DA <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 Ion r a hazardous waste as defined by 40 CFR 261. <br /> Ova '-s 6 — 20 <br /> Generator Authorized Agent Name Print 4. Signature r.Date <br /> TRANSPORTER Generator completes Ila-b alo Tr res orter corn fetes ilc-e <br /> a.Transporter's Name and Address: <br /> "S C+kll�c L1,X�} '.i 1057, _ `_rnera'� 3-+eft! - <br /> b. Phone: <br /> Sed - 0 1 <br /> c. river Name Print d. Si re e. Date <br /> III. DESTINATION (Generator complete Ilia-c and Destination Site completes Ilid-g) <br /> a. Disposal Facility and Site Address: C.US EPA Number d.Discrepancy Indication Space: <br /> F__R7k_`A 1D LP.'s;OFII!-f'': <br /> 9)57=.rL �t 7_-:i.CA 36 ..4 :. <br /> cert' t the ovp Ingm at I h b acq9pte nd to e t of my o led a the for of <br /> e e f u rueda not U,,Vature . Date <br /> IV. VAS6ESTOS (Generator completes IVa-f and Operator comp tate IVg-i) <br /> a. Operator's Name and Address: c.Responsible Agency Name and Address: <br /> CA�i?ilv.:CLF.._4i1A. <br /> b.Phone:`-" d. Phone: <br /> e.Special Handling Insbuctions and Additional Information: <br /> fY'^ r 4 `7 r ► r. <br /> _r._-r. z: 3f G. �Q�ut3:_ -ttr:%3r!sE".AWW: i—, Ing.,Pu:t04=x 990,RAdtWs. rA 9S352,20542' ii .=psi lam I�=ti' -I 1 <br /> f.❑ Friable`' Non-Friable ❑ Both % Friable _1 C.. •; %Non-Friable <br /> OPERATOR'S CERTIFICATION:1 hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name <br /> �d are classified,packaged,marked and Iabela&placarded,and are in all respects in proper condition for transport according to applicable international and <br /> tonal govern ental requlations. <br /> �30 �Z -- 2 — 1 7� <br /> g.O rator's Name and Title Print h. ature i. Date <br /> 'Operator refers to the company which owns,leases,o erates,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 />