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x <br /> REPUBLICS NON-HAZARDOUS SPECIAL WASTE & ASBESTOS MANIFEST <br /> SERVICES <br /> If waste is asbestos waste,complete Sections 1,11,111 and IV <br /> 6403280 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 /> N/A I <br /> d.Generator's Name and Location: a.Generator's Mailin Address: <br /> ervice I <br /> Traitor A <br /> ssiAssociated nactor Service loc oc� <br /> TraitorSnc. <br /> 34 Vent,ira Ave 1320 Charter Way <br /> f.Phone: ittykton,,A 95203 g. Phomptockton,CA 9b i6 <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 n Total o.Unit <br /> Description No. Type Quantity Wt/Vol <br /> f A <br /> 42U2045U 31/11/2021 Soil V1 <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 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 n is no longer a hazWous waste 4"S[ined by 40 CFR 2611 <br /> Ado% OF <br /> L^ee&1 <br /> p.GeneravAuthodzqMent Nam f(Plint) Signature/'olr r.Oalp <br /> II. fTRANSPORTER (Generator completes Ila-b and Transporter completes 11c-e) <br /> a.Transporter's Name and Address: <br /> + <br /> 11-1 ev­ <br /> b. Phonc. A <br /> Driver Name(Print) d.Si natur a.Date <br /> Ill. DESTINATION (Generator complete Ilia/ and Destination Site completes Hid-g) <br /> a.Disposal Facility and Site Address: c.US EPA Number d.Discrepancy Indication Space: <br /> Forward Landfill <br /> 9M S.Austin Rd. <br /> lti. Manteca,CA 95336 209-9&-4 298 <br /> I her cep!EVat the above named material has been acc d,4nd o the best of my knowledge the foreqoinq is true and accurate. <br /> a.RM6 of Authorized Agent(Print) I f.Si nature 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 [I 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 international and <br /> national governmental regulations. <br /> a.Operato 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 01/14 DESTINATION RETURN RS-F11A <br />