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9W W REPUBLIC NON-HAZARDOUS SPECIAL WASTE & ASBESTOS MANIFEST <br /> 1 <br /> 044 <br /> SERVICES <br /> r� w If waste is asbestos waste,complete Sections I,11,111 and IV <br /> r I 42464 If waste is NOT asbestos waste,complete Sections I,11 and III <br /> GENERATOR (Generator completes Ia-r) <br /> a.Generator's US EPA ID Number b. Manifest Document Number c.Page 1 of <br /> d. Generator's Name and,Location: } <br /> e.Generator's lylailing Address: <br /> FAS'Md t ETAt-r..trant'�zr'.i_i -LX 32 <br /> LInfor•: N! 1 a_�am gysg = -:3. CA gam=to <br /> 001 �=5_36•`tuoC,4 .C{A953a, -- :` <br /> - <br /> f. Phone: _. <br /> g. Phone: <br /> _ If owner of the generating facility differs from the generator,provide: <br /> h.Owner's Name: Manteca Ur.l*iad Scf-o,1 i.Owner's Phone No.: ='-S?5-312ClC <br /> j_Waste Profile# k.Exp. Date I.Waste Shipping Name and m.Containers n.Total o. Unit <br /> j Description No. Type QuantityWtNol <br /> 4 +tel CI b7 oc-mbar 27,2V 1;: Nor.Friable <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 268 and is no longer a hazardous waste as defined by 40 CFR 261. <br /> p. Generator Authorized Agent Name(Print) Signature ` r. Date <br /> TRANSPORTER Generator completes ila-b and Trans orter completes llc-e <br /> p. rransporters Name and Address: <br /> s <br /> Modesto. <br /> b_ Phone: <br /> c.Driver Name(Print) Xd ' ur � e. Date <br /> DESTINATION (Generator comp -c and Destination Site completes llld-g) <br /> a. Disposal Facility and Site Address! c.US EPA Number d.Discrepancy Indication Space: <br /> if-N <br /> C s <br /> .t'f. �: <br /> 1 <br /> I here fihat fF-e a5-bwe named mat s en d and to4he tlest of m piow � e-theJfbr. gainq is trLand accufate. <br /> e. Nam6 of �! <br /> � horiz ent P4mt r nature Date <br /> IV. ASBESTOS (Generator completes IVa-f and Operator complete 1Vg-i) <br /> a.Operator's Name and Address: c.Responsible Agency Name and Address: <br /> isrr�ca+lntltad Schaal P.O.Bax 52 <br /> lei t Ulan Rd <br /> b. Phone:W - '�{ dPhone: <br /> '_"` . <br /> e. Special Handling Instructions and Additional Information: `_ <br /> JG rr^_t;3r;.-' C:!a,Rerv�3v;l Co!frj=!'!s LT.F:CntGrr?t_!5t.Int.,P�St'r�}"6= � k .R '-r f - _�ty'� u h - Ito-111 <br /> r. C 3558,P aGiz4.&. A JS9S2,Zi'y- - E. .;0B L;M <br /> f.❑ Friable .tel 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 labeied/placarded,and are in all respects in proper condition for transport according to applicable international and <br /> -ral governmental regulations. <br /> Operators N&rrie and Title Print i n i. Date <br /> `Operator refers to the Company which owns 'ease , o es,controls,or supervises the fadlity being demolished or renovated, or the demolition or <br /> renovation operation or both - <br /> REV 01114 DESTINATION RETURN RS-F1 1A <br />