Laserfiche WebLink
REPUBLIC NON-HAZARDOUS SPECIAL WASTE & ASBESTOS MANIFEST <br /> SERVICES <br /> A 2284006 If waste is asbestos waste,complete Sections I,II,III and IV <br /> If waste is NOT asbestos waste,complele Sections 1,11 and III <br /> I. GENERATOR (Generator completes la-r) /C <br /> a.Generators US EPA ID Number b.Manifest Document Number c.Page 1 of �/ G <br /> d.Generator's Name and Location: e.Generators Mailing Address: APR U 8 015 <br /> Pacific Southwest Irrigation <br /> 8372 S.Jacklone CtYA rlV I <br /> I.Phone: Stockton,CA 209546-0791 g,Phone: �ON ENTAIL <br /> If owner of the generating facility differs from the generator,provide: ' T^ l rT/t <br /> h.Owner's Name: I.Owners Phone No.: <br /> J.Waste Profile# k.Exp.Dale 1.Waste Shipping Name and M.Con finers n.Total 0.Unit <br /> Description No. T e Quantliv WWol <br /> 4204153365 211042016 Soil CY <br /> i I - - <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 /> stale law,has been property 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 accordance with the requirements of 40 CFR 268 and is no longer a hazardous waste as defined by 40 CFR 261. <br /> if w 67%Aew 3 <br /> eneratorAuthorized Agent Name Print .Signature I r,Date <br /> I. TRANSPORTER Generator completes Ila-b and Transporter completes llc-e <br /> a.Transporter's Name and Address: <br /> b.Phone: <br /> c.Driver Name Print .titgnature a• <br /> Dox <br /> III. DESTINATION (Generator complete Illa-c and De (nation Site completes Illd-g) <br /> a.Disposal Facility and Site Address: c.US EPA Number d.Discrepancy Indication Space: <br /> Forward Landfill <br /> 9999 S.Austin Rd. <br /> b flet , 36 982.4 <br /> I hersbOceftify Qlat,thelaDwilin material ha been ac ted en to a Dest W MY KnOWted a the foregain <br /> e. eof Authorized ni Q.Dale <br /> IV. ASBESTOS (Generator completes IVa-f and Operator plete IVg-1) <br /> a.Operators Name and Address; c.Responsible Agency Name and Address: <br /> b.Phone: d.Phone: <br /> e.Special Handling Instructions and Additional Information: <br /> f.❑ Friable O Non-Friable ❑ Both %Friable %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 /> Ione governmental regulations. <br /> Operators Name and Title Print h.Signature f.Dale <br /> 'Operator refers to the company which owns,leases,operates,cenvois,or supervises the facility being demolished or renovated,or the demoiltion of <br /> renovation operation or both <br /> REV 01M4 •,Y+'if1CM Pt f!JRN RS-FliA '.. <br />