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REPUBLIC NON-HAZARDOUS SPECIAL WASTE & ASBESTOS MANIFEST <br /> SERVICES, INC. <br /> If waste is asbestos waste,complete Sections I, 11,III and IV <br /> If waste is NOT asbestos waste,complete Sections I,II and III <br /> I. GENERATOR (Generator completes la-r) <br /> N/A 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 /> Kent's Oil Service Inc,dba Pacific Northwest Oil Kent's Oil Service Inc,dba Pacific Northwest Oil <br /> 3310 E Minor Ave. P.O.Box 6930 <br /> Stockton,CA 95205 Stockton,CA 95206 <br /> f. Phone:209-948-0302 . Phone:209-948-0302 <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/V+OII <br /> 42041818050 12/31/2018 Soil l } 1� <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 /> L AJC w,o,.w It I <br /> p.Generator Authorized Agent Name(Print) q. Signature r. Date <br /> Ill. TRANSPORTER (Generator completes Ila-b and Transporter completes Ilc-e) <br /> a.Transporter's Name and Address: <br /> b. Phone: u <br /> c.Driver Name(Print) d.Signature e. Date <br /> III. DESTINATION (Generator complete Illa-c and Destination Site completes Illd-g) <br /> a. Disposal Facility and Site Address: c. US EPA Number d. Discrepancy Indication Space: <br /> Forward Landfill <br /> 9999 S.Austin Rd. <br /> Manteca,CA 95336 <br /> one:209-98"298 <br /> I her y cerci that t e above named material has beJacc nd t the best of m knowled a the fore oin true a d accur te. <br /> N of Au ho d A ent(Print aure . Date <br /> IV. AS ESTOS (Generator completes IVa-f and Operator complete IVg-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.❑ Friable ❑ 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 proper shipping name <br /> and are classified,packed,marked and labeled and are in all respects in proper condition for transport by highway according to applicable international and <br /> national governmental regulations. <br /> O erator's Name and Title PrintI 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 />