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�W� REPUBLIC NONHAZARDOUS SPECIAL WASTE & ASBESTOS MANIFEST <br /> SERVICES <br /> If waste is asbestos waste,complete Sections I.II, III and IV <br /> 4457736 <br /> If waste is NOT asbestos waste,complete Sections 1,II and III <br /> 1. GENERATOR (Generator completes is-r) <br /> a.Generator's US EPA ID Number b.Manifest Document Number c.Page 1 of <br /> d.Generator's Name and Location: e.Generator's Mailing Address: <br /> L &L <br /> 'i i2 fs`it�tl'•�3.ri_31 �f��# L;fi'v,. <br /> f. Phoneltggkto .CA -OP52'' 239_ =_�1015 g.Phone: �a J,HKA1 -d, --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# k.Exp_Date 1.Waste Shipping Name and M.Containers n.Total o. Unit <br /> Description No. Type Quantity Wt/Vol <br /> L� <br /> i GENERATOR'S CERTIFICATION: I hereby certify that the above named material is not a hazardous waste as defined by 40 CFR 261 or any applica,ble <br /> g if this <br /> state law,has been properly described,classified and packaged,and is in proper condition for transportation according to applicable reulatYons;AND <br /> waste is a treatment residue of a previously restricted hazardous waste subject to the Land Disposal Restrictins.t certify and warrant that the waste has <br /> o <br /> been treated in accordance with the requirements of 40 CFR 268 and is no to er a hazardous waste as defined by 40 CFR 2fr1. <br /> Generator Authorized Agent Name(Print) ! q. Signature r Date <br /> 11. TRANSPORTER Generator coo letes Ila-b and Trans orter compfetes Ilc-e <br /> a.Transporter's Name and Address: <br /> 6.Phone=. <br /> y . q574L 1 <br /> c.Driver Name Print P <br /> d.Si nature e. Date <br /> III. DESTINATION (Generator complete illa-c and Destination Site completes illd-g) <br /> a Disposal Facility and Site Address: c-US EPA Number d. Discrepancy Indication Space. <br /> e <br /> b. <br /> t hereby cerfify that the above named imateriat Lias beery acre and to the best of m. knowled a the face oim is true and axcwcaLe~ <br /> e_Name of Authorized Agent Print L Si• re Date <br /> IV_ ASBESTOS (Generator completes Wa-t and Operator complete llvg-� <br /> a..Operator's IlJaime and Address; [d. <br /> espossidUe Ageacy BVaff 7e and Adidiresm <br /> b.Phone: hmrte <br /> x Special.Handling,lbstructons anti Addflonali Itnforrmarir : <br /> fi p IFriable� Li Non-Friahl'e EY Bath %6 Hebb %Non-Friar -- <br /> OiPERATOit�S CERTIFICATOD� -R hweby kciare.that'tthe G0rr&mff$O tbis�are Mfg• m�mflrerB alf ltihe ym shipping and are¢lassifiedl.peckagfed.mrafked and ialbef �ufaoarrrfedl amdl arts in all @ �shi im nmreh <br /> resQeets um pumperr wardfimQrn foQ ttm API fthe imf irnseend and <br /> matimma4 governmental rec�wiabmms. <br /> © erafmr's:Name and Tithe•Prom Lti.Sl <br /> "Operator refers;ter t cmff. any wfnimlh!ovens,5oases.,mpemteA,cnnftls off m*ervcism the ifaci]'Ay ba rgp afinnalialhad or nimo a& or Me ftmomlii5mm�mR <br /> rtemovation a) eraViomm air bath <br /> REV U1!?4 <br /> DESTINATION RETURN Rs-F1ra <br />