Laserfiche WebLink
REPUBLIC NON-HAZARDOUS SPECIAL WASTE & ASBESTOS MANIFEST <br /> SERVICES <br /> 1 t'l Q If waste is asbestos waste,complete Sections I,It,ill and IV <br /> �J 8 If waste is NOT asbestos waste,complete Sections I,11 and ISI <br /> GENERATOR (Generator completes la-r) <br /> a. Generator's US EPA ID Number b. Manifest Document Number c. Page 1 of <br /> I .. ) ; Eno � i-7 <br /> d. Genera tt'AM�l ' f��M-f Fish and Wil�i� e. Generator's M.etilir�JrA1a A trltE3tFt of Fish and Wildife <br /> 21%Arch-Aiq)cft Rd. Ste 100 21LV Arch-MWA St. Ste 100 <br /> Stockton,CA 96206 209-234,31484 Stockton,CA 96ZM 209-234-3484 <br /> f, Phone: g. Phone: <br /> If owner of the generating facility differs from the generator, provide: <br /> h. Owner's Name: i.Owner's Phone No.: 1 <br /> j.Waste Profile# k. Exp. Date I.Waste Shipping Name and m.Containers n.Total o. Unit 1 <br /> Description No. Type Quantity Wt(Vol <br /> 4204YB1392 i=omyaiin pre9enved Fish&invertibra es <br /> GENERATOR'S CERTIFICATION: l 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 /> Generator Authorized Agent Name(Print) Lq,.St nature r. Date <br /> TRANSPORTER Generator completes Ila-b and Transporter completes Ilc-e <br /> a.Transporter's Name and Address: <br /> b. phone: <br /> c. Driver Name Print , d. Si nature I e, Date i <br /> 111. DESTINATION (Generator complete Isla-c and Destination Site completes Illd-g) <br /> a. Disposa�-F,Wer tr aw Address: c. US EPA Number d. Discrepancy Indication Space: <br /> S..Austin Rd <br /> Manteca,CA V5339 9Q,-429',, « <br /> I herebv cWify,that the:above named material has boen cc' ted,.and to the bes of my knowledge the foregoing is true and acc rat . <br /> e. Name o Atit#o 'e ..A Cnf rint ; f. 5i na red.,- . Date <br /> IV. ASBESTOS (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 0 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 /> -td are classified, packaged, marked and labeledlplacarded, and are in all respects in proper condition for transport according to applicable international and <br /> tional governmental regulations. <br /> O erator's Name and Title Print) <br /> _L.h...Sig nature 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 /> RFV 01/14 RE1"LJRN TO OPERATOR Rs-F11A <br /> F <br /> �I <br />