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4 <br />1 <br />11 11, <br />D r ante (Pr nt) <br />TRANSPORTER (Generator completes ila-b and Transporter completes c- <br />Transporter 's Nancikle471111tess: <br />V <br />. <br />kes-C C-7 3 7- )7.? _ <br />Phone: <br />e D e _J <br />III. DESTINATION (Generato <br />tore <br />m I te lila-c and Destination Site completes 111d-g) <br />c US EPA Number d. Discrepancy Indication Space: <br />the above named material has bee /a \tncl o the st of mOnowledge the fore <br />ad Agent Agent (Print) f. Siq <br />-lVaf nri On4or comolete IV <br /> <br />*SERVICES <br />REPUBLIC NON-HAZARDOUS SPECIAL WASTE & ASBESTOS MANIFEST <br />887921 If waste is asbestos waste. complete Sections I. II, 11i and ty <br />If waste is NOT asbestos waste, Complete Sections I, II and III <br />I. <br />a. Generator's US EPA ID Number I b. Manifest Document Number <br />N/A ---1-- <br />c. Page —I of - <br />d. Generator's Name and Location: <br />GM Expressa, Inc. <br />37.55'16.3 N, 121.1733.1 W, Hwy 5 <br />Stockton, CA 95206 909-505-2360 <br />f. Pnone• <br />e. Generator's Mailing Address: <br />GM Expressa. Inc. <br />19.953 Valley_ Blvd . Walnut, CA -90 i89 <br />g. Phone: <br />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 I. Waste Shipping Name and <br />Description <br />m. Containers n Total <br />Quantity <br />o. Unit <br />WtNol No. Type <br />4204209754 07/28/2021 SOIL ( CIP‘SIC <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 />bee treated in accordance with the requirements of 40 CFR 268 and is no Jongera hazardous waste as defined by 40 CFR 261. , <br />-7N _.....›..,--'---P-' <br />— ------ e_i ... - • . . <br />p. Generator Authorized Agent Name (Print) ignattie - — r. Dine , <br />iv. <br />Operators Name and Address <br />Phone: <br />Responsible Agency Name and Address: <br />Phone. <br />Special Handling Instructions and Additional Information. <br />0 Friable D Non-Friable 0 Both % Friable °.e, Non-Friable <br />OPERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name <br />and are classified, 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 />Operator's Name and Title (Print) Signature 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 04/19 DESTINATION RETURN RS-F I IA