Laserfiche WebLink
V:J) REPUBLIC NON -HAZARDOUS SPECIAL WASTE & ASBESTOS MANIFEST 7LGe 4 r <br />tS►� SERVICES <br />v <br />Ll bb3( <br />If waste is asbestos waste, complete Sections 1, 111 111 and IV <br />{f waste Is NOT asbestos waste, complete Sections i, If and Ili <br />1. GENERATOR (Generator completes la -r) <br />a. Generalos�iRIS EPA ID Number <br />3;. '!'R^.NuR^;'TEi? (Generator completes Iia -b and Trans oder completes <br />Q. Manifest Document Number f i JA <br />c. Page 1 of <br />d. Generator's Name and Location: <br />PorT of Stockton <br />2281 W. t# ashinton ST4 <br />Stockton CA 953 <br />f. Phone: 2 9-9 6ItI2116 x 291 <br />e. Generator's Mailing Address: <br />Pt! Boy, 2089 <br />atockicin, t'A 95X1 <br />g. Phone: <br />If owner of the generating facility differs from the generator, provide: <br />Purl Of SrockTorl <br />h. Owner's Name: <br />qq__ <br />I. Owners Phone 9/.t6-0216 x291 <br />j. Waste Profile # <br />k. Exp. Date <br />I. Waste Shipping Name and <br />Description <br />m. Containers <br />n. Total <br />Quantity <br />o. Unit <br />WtNal <br />No. <br />Type <br />5556101 <br />NaRvamticr50,2A11=a <br />NonFriable <br />BA <br />Y0 <br />b ers <br />FtUart%iheabowtmmodm;gerioftasba(ebaco6Dtedlana <br />� <br />� <br />1 <br />� <br />ame of <br />XuUi6rized A ent Pdni <br />f. Si ure f 0 P <br />e <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 actor ante with the requirements of 40 CFR 268 and is no longer a hazardous waste as defined by 40 CFR 261. <br />p. 16eneralor Authorized Agent Name <br />Print <br />. gnalure <br />r. Date <br />lit -e <br />a. Transporter.',�5 Name and Address: <br />U_ i _ t�:t�flent, {jt <br />' s3t fee, ow 42 ?. rfg. �t J� �a. P11memid Avenue <br />{�1fc�destc�7 C� <br />b. Phone: If <br />Driver Name Print d. geature e. Date <br />DESTINATION <br />(Generator complete INa-c and Destination Site completes Iur1-n1 <br />a. Disposal Facility and Site Address; c. US EPA Number d. Discrepancy indication Space: <br />FCakiA,;.^.fcD LANDFILL, RK., <br />IY. R7tit51 U5 (Uenera[Or COfrlplete5 IVa -t and operator <br />9999 . s L15'TI d R Alit MANTEt`a, CA 9 6 <br />ca c o 0 0 t o v a <br />1 1 <br />r <br />b ers <br />FtUart%iheabowtmmodm;gerioftasba(ebaco6Dtedlana <br />otlYebbstof <br />owlaiiathp-fnrh-nninnic:lrjip;inri cc e. <br />1 <br />� <br />ame of <br />XuUi6rized A ent Pdni <br />f. Si ure f 0 P <br />e <br />a. Operators Name and Address: <br />Plitt of �tGtkton <br />210 1�/. btrpshtn,�cn St. - <br />5tackfan, Cel 1952103 <br />G <br />nom___. it}S'?46OI4E!S?YI <br />Instructions and <br />;ol�piete <br />c. Responsible Agency Name and Address: <br />PO Sok 2313: <br />Stockton, :A9521? <br />d. <br />00 nnt0raak b:Bs. Removal Cnntr.ctar is tr.7-�oat�rnart, Ing, Fu',tti`'tC: &a�. ?5�a, F:�ckrscts, � g5gs2: i4e-.2a-Bb11 C.. T . !�!5 f111 �98Ei{� 13-57'9 <br />OPERATOR'S CERTIFICATION: 1 hereby declare that the contents of this consfgntnent are fully and accurately described above by the proper shipping Warn <br />and are classifed, packaged, marked and labeled/placarded, and are in all respects in proper condition for transport according to applicable international and <br />national governmental regulations. <br />company <br />z <br />ownsI <br />or supervises the <br />REV 12/10 C,}t?STItd�?7�I:.;�N ftiE�� t3r�$�8 <br />or renovated, or the demoltuon or <br />RS-F11A <br />