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REPUBLIC' NON-HAZARDOUS SPECIAL WASTE & ASBESTOS MANIFEST <br /> SERVICES <br /> If waste is asbestos waste,complete Sections 1,11,111 and IV <br /> 6352303 If waste is NOT asbestos waste,complete Sections 1,11 and III <br /> 1. GENERATOR (Generator completes la-r) , <br /> a.Generator's US EPA ID Number b. Manifest Document Number c. Page 1 of <br /> d.Generator's Name and Location: e.Generator's Mailing Address: <br /> Ass(mated I ractor Service im Associated Tractor Service ir,(, <br /> 34 Ventura Ave 1323 Charter Wav <br /> f.Phone: ktonA 962(Y3 9M,4 15 6-3 0_0-3 9- Phoneq <br /> ,toCktop <br /> CA 95? <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 1.Waste Shipping Name and m.Containers I n.Total o.Unit <br /> Description No. Type I Quantity Wt/Vol I <br /> -4AV42045U— 311342)21 Soil <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 properly 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 w ste�sub%lo the Land Disposal Restrictions. I certify and warrant that the waste has <br /> been treated in accordagpe with the reo '!Vments of 40 CFR 268,7nd er a hazy W"waste as defined by 40 CFR 261. <br /> b <br /> 7 <br /> p.Generator A16thorized Agent Name(Print q7Signat re z r. Date <br /> II. TRANSPORTER (Generator completes lla-b and Transporter completes llc-e) <br /> a.Transporters Name and Address: <br /> b. Phqne: 12-LI <br /> e. Date <br /> l d. SignatWe <br /> c D�kame Print <br /> III. DESTINATION (Generator complete Ili -c and Destination Site completes Illd-g) <br /> a.Disposal Facility and Site Address: c.US EPA Number d. Discrepancy Indication Space: <br /> Forward Landoll <br /> 9W9 S.At*tin Rij- <br /> b. Manteca CA 95336 X&.CkQ--0911 <br /> I hereby c the above named material has been accepted to the best of my knowledge the foreqoinq is true and accurate. <br /> ht( 24 <br /> e.Namt-oKAUI:Forized Agent(Print I f.Signature --------- ----- g. Date <br /> IV. ASBESTOS (Generator completes IVa-f and Operator complete lVg-i) <br /> a.Operator's Name and Address: c. Responsible Agency Name and Address: <br /> b. Phone: d. Phone: <br /> a.Special Handling Instructions and Additional Information: <br /> f.0 Friable 0 Non-Friable 0 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 intemational and <br /> national governmental regulations. <br /> g.Operator's Name and Title(Print) I 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 01/14 DESTINATION RETURN RS-F11A <br />