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REPUBLIC NON-HAZARDOUS JPECIAL WASTE & ASBESTOS MANIFEST <br /> SERVICES <br /> if waste is asbestos waste,cornoto Sactions I.II,III and IV <br /> 2878632 <br /> If waste is NOT asbestos waste,complete Sections I,II and III <br /> I. GENERATOR (Generator completes la-r) <br /> a.Generator's US EPA ID Number b.Manifest Document Numter c.Page 1 of <br /> WA <br /> d.Generator's Name and Location: e.Generalor's Mailing Address: <br /> Stockton Metroplilen Airport Stockton Mclroplilan Airport <br /> 5000 S.Airport Way 5000 S.Airport Way <br /> f.Phone: Stockton,CA 95206 209465.4700 g.Phone: Stockton,CA 95206 209-468-4700 <br /> If owner of the generating facility differs from the generator,provide: <br /> h.Owner's Name: I.Owner's Phone No.: <br /> J.Waste Profile# k.Exp.Date L Waste Shipping Name and m.Containers n.Total o.Unit <br /> Description No. Type Quantity WVVOI <br /> G� f <br /> I l31 t1 t 0 T-o N <br /> 42041520309 1211!2016 Soil <br /> GENERATOR'S CERTIFICATION: I hereby certify that the above named material is nal 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 26"d is no longer a hazardous waste as defined b 40 CFR 261. <br /> HARRY MAVRo6-E,rill� 5 7. <br /> p.Generator Authorized Agent Name(Print) rgnature r.Date <br /> 11, TRANSPORTER Generator completes Ila-b and Transporter completes Itc-e <br /> a.Transpprters Name dyd AdfJrossy�, � 3_ <br /> b.P ne: J <br /> c,-(�S <br /> c.Driver Name Print d. ura e.Dal <br /> III. DESTINATION (Generator complete Illa-c and Destination Site completes 111d-g) <br /> a.Disposal Facility and Site Address: US EPA Number d.Discrepancy Indication Space: <br /> Forward Lendfdl <br /> 999,9 S.Austin Rd. <br /> b teca,CA,95W 209,W 4298 <br /> I fereby tirt at th abo a naqje4 n1alferial has beefi,,accepltdjand b4itfie f ITW knowled e e Fore oin Is lr a Ad a c l . <br /> e. e f Authori d Mont Print f.Signa-MM— <br /> IV. <br /> i na IV. ASBE S (Generator completes IVa-f and Operat&complete IVg-I) <br /> a.Operator's Name and Address: EPhs.pn'1. <br /> sible Agency Name and Address: <br /> b,Phone: <br /> e.Special Handling Instructions and Additional Information: <br /> f.O 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 labeledlpiacarded,and are In all respects in proper condition for transport according to applicable internatlonal and <br /> national governmental re Mations. <br /> q.Operator's Name and Title Print h.Signature I I.Dale <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 01/14 DESTINATION RETURN RS•F11A <br />