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f <br /> E! efT �• i. Y ' <br /> REPUBLIC NON-HAZARDOUS SPECIAL WASTE & ASBESTOS MANIFEST <br /> I: _sertvrcr s, rnrc: x -' .._ v , <br /> If waste Is asbestos waste,complete sections 1,11,111 and IV <br /> if waste is R01 asbestos waste,complete Sections 1,11 and tit <br /> I. GENERATOR Generator completes la-r <br /> s.Generator's US EPA ID Number t b,Manifest Document Number`} o�+ r t Page 1 of <br /> ,,NIA ". - _ 1Z <br /> : • q 1 <br /> d.Generator's Name and Location: o.Generator's Malang Address: <br /> d.Gro rao'station Na a Valero-California Retail Corporation <br /> 1210 E.Hammer Ln. 685 West Tlrlyd St. <br /> Stockton,CA 95210 Hanford,CA 93230 <br /> f.Phone:559-583.3231 a.Phone:559-583-3231 <br /> If owner of the genamtIng facility differs frdm the generator,provide: <br /> h.Owner's Name:' I.Ownare Phone No.:.... <br /> 1.Waste Profile# k.Exp.Dale 1.Waste Shipping Name.and c 4 ; m.Containers. n.TOfal,. o,.Unit <br /> Desai tion No, T Quant{ INtN01 <br /> ID852 _ 02/05114 Soil 00" Tons <br /> R - <br /> f GENERATOR'S CERTIFICATION: I hereby certify that the above named material is not a hazardous waste as dellned by 44 CFR 26i or any applicable <br /> state taw,has been properly described,classified,and packaged,and-is In proper condition for transportation according to applIcabie regulations;AND,a this <br /> o the Land Disposal Restdclions. 1 certify and warrant that the vraste has <br /> waste subject t p <br /> previously restricted hazardous ] <br /> waste Is a treatment residua of a p y <br /> -been treated In accordan with the re uirementd of 40 CFR 268 and Is no Ion hazardous waste as defined by 40 CFR 261. <br /> Larry Moothaxt of HBSI on behalf of 2/15/2013 _ <br /> generator <br /> 4 o.Generator Authorized Agent Name Prin Si nature. r.Date <br /> ' II. TRANSPORTER. Generator completes Ila-b and Transporter completes110-t) <br /> a.Transporteea Name and Address: T „`` -:„ <br /> LD Transportation It 5C �0 S <br /> 538 Santa Teresa CA <br /> Vacaville, 88 1�C S 1 0�I SlD�tip <br /> b.Phone: -_ <br /> Il r.DrIverNam(PrInQ Id.Signature _ 9.Date_ <br /> III. DESTINATION:(Generator complete Ilia=c and Destination Site completes lild-g) <br /> a.Disposal Facillty and Slid Address: c.US EPA Number d.Discrepancy Indication Space: <br /> Forward Landfill <br /> 4 <br /> 9599 S.Austin Rd - 4 <br /> Manteca,CA 95335 "*' <br /> b.Phone:209-9821298 <br /> I herb certify that the above named material has been t _anti t the e o led a the fore cin is true and ac rat <br /> e.Name of Authorize q.Date <br /> IV. ' ASBESTOS. (Generator completes Ala-rand• Operator mplete IVV) b. <br /> A.Operator's Name and Address. <f Responsible Agency Name and Address: <br /> b.Phone: _ -.. d.Phone: <br /> e.Special Handtfrng Instructions and Additional Information: <br /> pedlonal <br /> fe NonBath 95 Friable 4fo Non-Friable <br /> RS CERTIFICATION:I hereby declare that the contents of this consignment are fully end accurately described above by proper shipping name <br /> asslfted,packed,marked and labaled and are In all respects In proper condition for transport by highway according to applicable international and <br /> ovemmantal r ulations. <br /> p DalDds Nameand Title Print h.Sf nature - e refers to the company which owns, pees,operates,centrals,or supervises the facilityibeft demolished or renovated,or the demolilEon or operation ar both - .' m"' <br /> A 4970 Windolav drive.#C5 • P Dorado Mi s,CA 95762 • (916)939-2170 • FAX(916)939-2172 <br />