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R <br /> 4k4 W REPUBLIC, NON-HAZARDOUS SPECIAL WASTE & ASBESTOS MANIFEST <br /> SERVICES <br /> If waste is asbestos waste,complete Sections 1,11,111 and IV <br /> If waste is NOT asbestos waste,complete Sections 1,11 and III <br /> 1. GENERATOR (Generator completes ]a-r) <br /> a.Generator's US EPA ID Number b. Manifest Document Number <br /> c.Page 1 of <br /> WA <br /> d.Generator's Name and Location- e.Generator's Mailing Address: <br /> Aseoil;Wad Tract&%rvice inc A"cioisted Tractor SeNm inc <br /> 1323 Chadw Way 1323 Chsiw Way <br /> f. Phone: StocM0.CA 9M MAW-= g.PhoneftCft,CA 962M <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 /> 31110211.... Sol <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 tre in accordance with the requirements of 40 C17and ino I_qnger a hazardous taste as defined. by 40 CFR 261. <br /> - <br /> p�. enerakor,Authorized Agent Name Print q.Si na urns r.Date <br /> IL TRANSPORTER (Generator completes Ila-b and Transporter completes llc-e) <br /> a.Transporter's Name and Address: <br /> b.Phonk /* <br /> L/ <br /> z i wl to i T-KIW <br /> LE.Driv"ame(Print I d.Signature / I e.Date <br /> Ill. DESTINATION (Generator complete Illa-c./iind Destination Site completes Illd-g) <br /> a.Disposal Facility and Site Address: c.US EPA Number d.Discrepancy Indication Space: <br /> FamfudLOK111111111 <br /> OW S.AWIin ft <br /> b. UW4M CA 9M 20D902-40* , <br /> 1 hoFe4y certify hat the above named material has been accepted,/and to the best of my knowled2e the fore going i true and accurate. <br /> C- <br /> I– � I L <br /> I—e-.Name ofAuthorizedAgent(Print) I f.Tianature n 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 /> e.Special Handling Instructions and Additional Information: <br /> f.0 Friable El 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 nar, <br /> and are classified,packaged,marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable international ani <br /> national governmental regulations. 1 <br /> 2.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 01/14 RETURN TO GENERATOR RS <br />