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REPUBLIC NON•"—iZARDOUS SPECIAL WASTE & ,--BESTOS MANIFEST <br /> fs►� SERVICES 'Ift", �� <br /> 1 9 G 5 If waste is asbestos waste,complete Sections II.III and 1V <br /> If waste is NOT asbestos waste,complete Sections 1,11 and III <br /> I. GENERATOR (Generator completes la-r) <br /> a.Generator's US EPA€D Number b. Manifest Document Number c.Page 1 of <br /> NIA <br /> d.Generator's Name and Location: e. Generator's Mailing Address: <br /> Den's Auto Den's Auto <br /> 308 South EI Dorado OX Fsgt Gann Rd <br /> f. Phonegtockton,CA 96203 20a-482-1 g.Phone: Stockton,CA 95231 209-462-IM <br /> If owner of the generating facility differs from the generator,provide: <br /> h.Owner's Name: Li.Owner's Phone No.: <br /> j.Waste Profile# k. Exp. Date I.Waste Shipping Name and m.Containers n.Total o.Unit <br /> Description No. I Type Quantity Wt1Vol <br /> 4204139473 6/512014 Soil fti, r Y-ocy <br /> B. <br /> C. <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 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 /> p.Generator Authorized Agent Name Print .Signature r. Date <br /> II. TRANSPORTER Generator completes Ila-b and Transporter completes Ilc-e <br /> a.Transter's Name and Address: <br /> UADta Container <br /> 1145W Charter way <br /> b.PhonPockton.CA 95206 <br /> c.Driver Name Print i nature I e.0 e <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 /> Fofward Landfill <br /> 9999 S.Austin Rd. <br /> b Manteca,CA 96338 208 M-4298 <br /> 1 hereby certify that the above named material has tleen acce toO)PeWtolthe b s of my knowled a the fore oin a ajqTratet, <br /> e.Name of Authorized Agent Print f. i na .D e <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.O 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 /> o.Operator's Name and Title Print h. Signature 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 /> renovation operation or both <br /> REV 12/10 DESTINATION RETURN RS•F11A <br />