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fit COattat0.7. <br />Owners Phone No <br />Ii Exp Date <br />n Total 0 Unit <br />Quantity WINN <br />h Owner's Name <br />I Waste Profile a Waste Shipping Name and <br />Descnphon <br />I. GENERATOR (Getter <br />a Generators US EPA ....014umner <br />mpletes ia-r) <br />b Manliest Document Number C Page 1 co <br />v.Zityrtuoattend Location <br />37.5238-12122017 <br />I MOM CA 95200 20P-3294441 <br />If owner of the generating facility differs from the generator provide <br />I a Gt,,,4 r Atiress <br />1816 Chatheid Ct <br />Stockton. CA 95209 209-329-64-41 <br />4204228050 6/18/2023 <br />Ok <br /> <br />jr_ No Type <br /> <br />GENERATOR'S CERTtFICATiON- t 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 paclusged, and is in proper condition for transportation accordrrig to Malleable regulations- AND, if this <br />waste is a treatment residue of a previousty restricted hazardous waste sublect to the Land Disposal Restrictions I certify and warrant that the waste has <br />b Phone <br />e Data <br />a r arid $ee Address <br />Fwd !meg <br />9999 S. Atrtn Rd <br />b MartirtC11. CA 95338 <br /> <br />s t, <br />I ii Irt <br /> <br />I <br /> <br />1 1! nas <br /> <br />a ie4MD <br />LT, <br />been treated in accordance with the requirements 01 40 CFR 268 and is no a hazardous waste as defined by 40 CFR 281 <br />r Dale • <br />E/ 4 <br />tam A..., <br />x4arne (Print <br />HI. DESTINATION (Generato <br />A :eat Name (Print) q Signatere <br /> TRANSPORTER (Generator completes Ila-b and Transporter completes 11c-e) <br />a Transporter's Name and Address. /!:\ s- v ceo-v‘24 1-1) r 06 ( <br />20 ) 2_6 - )() (D <br />S n <br />complete lila-c and Destination Site completes 111d-g) <br />c US EPA Number d Discrepancy Indication Space <br />- g- <br />209-982-4298 <br />arid to the my knowledge the for rig is true <br />e Nan], • Authorized Agent (Pnnt) f Signature <br />. ASBESTOS Generator completes IVa-f and Operator complete IVg-i) <br />I ate <br />REPUBL tikIN SEA :1CkS <br />2274317 <br />-HAZARDOUS SPECIAL WASTE & ASBESTOS MANIFEST <br />aste is asbestos 14.1ble cznipiete Sections I. II, tu and Iv <br />este is NOT asbestos waste. complete Sections i II and Ill <br />a Operators Name and Address <br />b Phone. <br />c Responsible Agency Name and Address <br />d Phone <br />Special Handling Instructions and Additional Informabon. <br />I 0 Friable 0 Non-Friable 0 Both % Friable Vci Non-Friable <br />OPERATOR'S CERTIFICATION I hereby declare that the contents ot this consignment are fully and accurately described above by the proper shipping <br />and are classified. Packaged, malted and laheledlOacardad• and are in all respects in proper condiaon for transport according to applicable internale:Mal and <br />national governmental regulations <br />g Operator's Name and Tide (Pnnt) h Signature i Date <br />*Operator refers 10 the osnipeny which owns, leases, operates. controls. or supervises the facility being demolished or renovated, or the demolition or <br />renovabon c9eration or both <br />REV ottle <br /> DE STINATION RETURN <br />Ft&Filik