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i <br /> REPUBLIC NON-HAZARDOUS SPECIAL WASTE & fjb�tl 9d�otiN <br /> SERVICES <br /> 17 J ) r r) II waste Is asbestos waste,complete Sections I.if.ill and IV 9`OZ 0 Nd <br /> _l 19 3'3 [,[.. If Waste Is NOT asbestos v7asle,XnjphdS Sections 1,11 and III I, <br /> I. GENERATOR (Generator completes la-r) 5 <br /> G� <br /> aNJanerator's US FPA D 'umber Lb.Manifest Doo1cu�-j{leent Nu�m7ber <br /> Fn�.ird-ti,SnECiC 1G e.[ xnafFlbn's Mxiliny ftrMlresr: <br /> d. Generator's Name and Locution: PO BOX.7640 <br /> (J JV -S G r�� 1 �'nL `r'� 5AN FW,NCI5CO,CAy4120 <br /> �!�zrh n.Phone UUU-1151-bULPJ <br /> _ <br /> I. Phone: _ _ <br /> If owner of the generating facility differs from the generator,provide: <br /> I.owner's Phone No <br /> h.Owner's Name: _ - _ _ - <br /> _ _ - - m.Container_ n.Total o• <br /> J.Weare Profile 8 k.Exp.Dale unit <br /> I.Waste Shipping Name and No T QuantityWVVDI _ <br /> Description _ _ _--__ -- <br /> /r - - — <br /> /2 I NON RE61-11AlED KWERIAL ' Y <br /> A2(hYp11178 r II ( SPILL MATFRIAl-) CM <br /> c <br /> GENERATOR'S CERTIFICATION: I hereby certify that the shove named material Is nal 11 hazardous waste as defined by 40 CFR 287 it any applicable <br /> wattles a a treatment <br /> o due of described. <br /> cribe.classified resand cted packaged,zardous waste subiis III racl5I,Ill rt awt nisposat1fl-111 to' rReshi l ns(Ittledily Sell lwarranttlhat the hw waste <br /> 1141, s <br /> been treated In accordance with the requirements of 40 CFR 268 and is uo longm a bazuldous Waste as delulod hruR 261. <br /> ats <br /> p Ganur dor Augmnzod AyallName Pith) q .- <br /> p. _ TRANSPORTER Generator col{�I3lcti I_le-b and Transnorlor compleU+s Ilc-_O),� <br /> 1802511ELTONDR b;I, 4• pTRF ' 03 L- <br /> HOLLISTF.fi,CA 95029 110(}821-1030110(}821-1030030 - <br /> h. -one: <br /> e..Dale♦ r <br /> c_OdverNa a(Print <br /> 9--- <br /> III. DESTINATION (_G_oiteraloi complete Illa-c and Destination Site_completes 11111-0) <br /> a.Disposal facility and Sile Address -c>l1S EPA Number d.Dlscrpency Indicalbn Space: <br /> FORWARD LANDFILL I <br /> ttrrl'; ni l;i <br /> i+!ROAD I _.. <br /> b r.5. . hi, r 209-932 4293 <br /> I ereby I lh�abovr)flail m lenal Ills hm•n a a dad.. nd to the boslfnf n knowledge Me fa num 1 ue a6d acbor6te._Tr <br /> I.siunaturo - <br /> o.Ne_me oLAulhorized;A�genl I"I � -- •- - <br /> IV. ASBEST& (( enerator completes IVa-f and Operator ctmnplete IVg=i) <br /> a.Operator s Name and Address c.Responsible Agency Naaw and Address: <br /> 1 <br /> d. Phone: - <br /> b Phone: - --- - - - - <br /> e.Special Handling Instructions and Addillonal Information <br /> f'- Friahle O Non-FrVahls O Both %Friable- %Non-Friable _. _ <br /> OPERATOR'S CERIrlOwrkedrand rbe erdrpl.net <br /> mded,fhe contents <br /> larari^nis all respec155in proper aondi�on for transport sic ording to applirablepinternallonel and <br /> and are classified,packaged, _ -- --- -- <br /> national mental reputations._ - - - - - -- <br /> govern- -- _- I-h:3� glare --- — ---- --. J.i.Oa,e - - - -- --- - <br /> g.Oporator's Name and Title(Print _ 4M- - - <br /> 'Operator rolers Ir.Ile•rzxhgr:uly whit owns,leases,operates,controls,or supervisor Ihn hrrilay h^-ng rinmotlsimd or rnn5waled,or the demoilll^n or <br /> renovation ilroralion ra both _ _ -- - _. _ - - - RS-Fl 1A <br /> REI'01!14 <br />