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d.Generator's Nettle an Location: a.Generatti MallinQ Address: <br /> HrPftark un'fformserrases Nrar(81fi U i oss:SErVIC <br /> 7679 s longe st 7674 S l4 St <br /> f. Phone: <br /> Stockton ca 95206 7 479-9527 g. Phone: Stockton ca.95206 708-479-4527 <br /> If owner of the generating facility differs from the generator,provide: <br /> h.Owners Name: I.Owners Phone No.: <br /> j.Waste Profile# k.Exp.Date 1.Waste Shipping Name and m.Containers n.Total o.Unit <br /> Description No. I T—ype Quantity WUVoI <br /> 1S <br /> 4/13M15 Plastic&debris V <br /> I TI <br /> GENERATO ' CERTIFICATION: I hereby certify that the above named material is nota hazardous waste as defined by 40 CFR 261 or any applicable <br /> state 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. 1 certify and warrant that the waste has <br /> been t ated in accords with Te requirements of 40 CFR 268 and Is no longer a hazardous waste as defined by 40 CFR 261. <br /> �a JW AN 40k YYVES o4klk I I <br /> p.Gen.ra4x Authorized Agdnt Name Print I q.Signature r.Date <br /> II. T NSPORTER Generator completes Ila-b and Transporter completes llc-e <br /> a.TransporteMl IVIAoOMBM RIAL SERVICES _M AL <br /> 1t'r.,2'' SHELTON DR <br /> b. Phone: nvuua ran,w ens aertwu r?ac—go <br /> •-�� -R� <br /> c.Driver Name Print d.Signature 1 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 /> Forward landfill <br /> S.Atstin rd <br /> b. Manteca ca.95336 2Q9 982-4 <br /> I hereby certify that the above named material has been accepted and to the best of my knowledge the foE�qoing is true and accurate. <br /> e.Name of Authorized Agent Print f.Signature I g.Date <br /> IV. ASBESTOS (Generator completes IVa-f and Operator complete IVg-i) <br /> a.Operator's 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 ❑ 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 /> national governmental regulations. <br /> .Operator's Name and Title Print h.Si nature I I. 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 /> renovationoperation or both <br /> REV 01114 - - ��""`` RS-F11A <br /> REG`IVEL <br /> MAY 13 2015 <br /> ENVIRONMENTA(. <br /> UCA,rU r IZOAOTIACAR <br />