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� F NON-HAZA <br /> R[f..US SPECIAL WASTE &(-3BESTOS MANIFEST <br /> tf waste Is asbestos waste,complete Sections I Ii,In and ry N o. 512 215 <br /> If waste Is NOT asbestos waste,complete only Sections I,II and III �g <br /> rI _` _4 <br /> a� Generator Name pj1C0 PRO VCTS COMPANY b Generating Location AREA STA^IOU 206020 <br /> c Address Ptd 5077 d Address 1711 E' YOSEMITE <br /> EUEM PARK, CA ,622-SO77 MAtP r.(Nk, CZ , <br /> e Phone No (925) 299-31891 PAUTL SUPPLE f Phone No H/A <br /> If owner of the generating facility differs from the generator,provide <br /> g Owner's Name NICO PRO <br /> ^LIC17- COMPAHY h Owner's Phone No rWW eLs I(a) <br /> C A D 5 (15 1 2 g 9 D i O 5 0 TYPE <br /> i BFI WASTE CODE Containers DM-METAL DRUM <br /> DP -PLASTIC DRUM <br /> NON-}]R2.AI 1yXS SnIL B -SAG <br /> I Description of Waste k Ou ntity Unds No TYPE BA -6 MIL. PLASTIC BAG <br /> 0 0 0110 Y� m or WRAP <br /> � T -TRUCK <br /> ' O -OTHER <br /> GENERATOR'S CERTIFICATION I hereby certify that the above named material is not a hazardous waste as defined by 40 CFR Part 261 or UNITS <br /> any applicable state law has been property described classified and packaged and is in proper condition for transportation according to P -POUNDS <br /> applicable regulations AND,If the waste Is a treatment residue of a previously restricted hazardous waste subject to the Land Disposal Y -YARDS <br /> Restrictions I certify and warrant that the waste has been treated in accordance with the requirements of 40 CFR Part 268 and is no longer a M' -CUBIC METERS <br /> hazardous waste as defined by 40 CFR Part 261 at the rc qm s* !'C AReo PW.)DUC TS CoF w r,4jY Y' -CUBIC YARDS <br /> MMI SSA YIRN/ DILIARD E-N-VIR00. ' tt ----� '1, i, *- O -OTHER <br /> Generator Authonzed Agent Name Signature Shipment Date Y' <br /> �-? Trans RBf COm <br /> � ra zr Pz f <br /> Seco©f« � �a _. TRANSP�OHTER (generator conaple�e N. Transrter n aom IeteV, <br /> TRANSPORTER I TRANSPORTER H <br /> MILL,RD TRIUC1L1h.G. If C. <br />�a Name h Name - <br /> POE <br /> b Address i Address <br /> YRON, Cr. 1451; <br /> o Driver Name�tle I ` ` :_ i ��' rf F=' } Driver Name/1 itle <br /> 6 34-053 PRINTF YPE J l t PRINTrME <br /> d Phone No, 4W - '- ` `e__Truck N.oc' -k Phona No - -— - 1--Truck No <br /> f Vehicle License No/State r ' ' l - - m Vehicle License No/State - <br /> r Acknowledgement otRec pt of Materials Acknowledgement of Receipt of Materials <br /> �r ��, ��, i f , <br /> s n <br /> Driver Signature Shiprmnt Date I Driver Signature shipment Date <br /> _ zd5 ,., 4A <br /> SectivftIIIMYy E� _ DESTINATIC)N4"i-(Gerieiatorcompletesad,desbnatiotislteconnpletese-f) ;� `T YS <br /> ir'1AD 57.01 ARY Le eDFI I, (925) 44:�.,���1 <br /> a Site Name c Phone No <br /> 4001 N. vA`,—j }�,ZI) 4G 1 'D• <br /> b Physical Address d Marling Address <br /> I.Zli-I2lit)I2}:, C1 9S�tJ LIti ):.tx:�r:• r.:A 94550 <br /> e Discrepancy Indication Space <br /> I hereby certify that the above named material has been accepted and to the best of my knowledge the foregoing is true and accurate <br /> t .-F:m 1ti�7;207 <br /> Name of Authorized Agent Signature Receipt Daie <br /> Section W ASBESTOS (Generator complete a-d f g,Shipper-completes e) <br /> a Shippers's"Name b Shippers's* Phone No <br /> c Shippers's*Address <br /> d Shippers's Special Handling Instructions and additional information <br /> CERTIFICATION I hereby declare that the contents of this consignment are fully and accurately described above by proper shipping name and are classified, packagE <br /> mafked and labeled/placarded and are in all respects in proper condition for transport according to applicable International and national governmental regulations <br />