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�Rw REPUBLIC' NON-HAZARDOUS SPECIAL WASTE & ASBESTOS MANIFEST 44 SERVICES If waste is asbestos waste,complete Sections I,If,III and IV 5310960 If waste is NOT asbestos waste,complete Sections I,II and III t GENERATOR (Generator completes la-r) Generator's US EPA ID Number Tb--Manifest Document Number c.Page 1 of d.Generator's Name and Location: e.Generator's Mailing Address: f. Phone- g.Phone: If owner of the geperating facility differs from the generator,provide: h.Owners Name: i.Owner's Phone No.: j.Waste Profile# k.Exp.Date I.Waste Shipping Name and I m.Containers n.Total o.Unit Description No. Type Quantity wwol GENERATOR'S CI ZTIFICATION: I hereby certify that the above named material is not a hazardous waste as defined by 40 CFR 261 or any applicable state law,has been properly described,classified and packaged,and is in proper condition for transportation according to applicable regulations;AND,if this 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 been treated in accordance with the requirements of 40 CFR 268 and is no longer a hazardous waste as defined by 40 CFR 261. p.Generator Authorized Agent Name Print o-Signature _ r.Date TRANSPORTER Generator completes Ila-b and Transporter completes lic-e Transporters Name and Address: b.Phone: c.Driver Name Print d.Signature e•Date III. DESTINATION (Generator complete Illa-c and Destination Site completes Illd-g) a.Disposal Facility and Site.Address: c.US EPA Number d.Discrepancy Indication Space: r t;wow�fli 999 S Austin Rd �nleca CA*3 b I hereby certit that the above named material has been acce and to the best of m Imowled the foregoing is true and accurate. �6.Name of Authorized A-antPrintf.Si nature . nate IV. ASBESTOS (Generator completes IVa-f and Operator complete tVg-i) a.Operator's Name and Address: c_Responsible Agency Name and Address: b.Phone: d.Phone, e.Special Handling Instntctions and Additional Information: f. Friable ❑ Non-Friable ❑ Both %Friable %Non-Friable OPERATOR'S CERTIFICATION:I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name and are classified,packaged,marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations. _ O erators Name and Title Print i h.Signature I I.Date Operator reters to the company wnlcn owns,leases,operates,controls,or supervises the facility being demolished or renovated,or the demolition or renovation operation or both — REV 01/14 RETURN TO OPERATOR R8 F11A