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4e REPUBLIC NON-HAZARDOUS SPECIAL WASTE & ASBESTOS MANIFEST k <br /> �V SERVICES <br /> If waste is asbestos waste,complete Sections I, 11, III and IV <br /> 1 w , If waste is NOT asbestos waste,complete Sections I, II and III <br /> n , <br /> .? GENERATOR (Generator completes la-r) <br /> J a. Generator's US EPA ID Number b. Manifest Document Number c. Page 1 of <br /> d. Generat fvame nd Locati n. e. Generator's Mailing Address: <br /> ��AMiR C rfftx 7 of Fish and M14% akfbfne Dwart ent pf Fist and Wktlife <br /> 2140 fth-AtrW Ra.Ste 100 2108 Afd Ai"9t. Ste 1(X) <br /> f. Phone: <br /> ;orkton,CA 9525 209-234.-348 g. Phone: Stmk€nr.Ldp W206 2)9-73�4484 <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 I.Waste Shipping Name and m. Containers n.Total o. Unit <br /> Description No. Type Quantity Wt/Vol <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 /> F--, Generat,r Authorized Agent Name(Print) q. Signature r. Date <br /> TRANSPORTER Generator completes Ila-b and Transporter completes Ilc-e <br /> a.Transporter's Name and Address: <br /> E� <br /> b. Phone: <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 /> For*wd wdhil <br /> S.Altstin Rd. <br /> Mantm.a.CA 9-4336 <br /> I hereby certify that the above named material has been accepted and to the best of my knowledge the foreacing is true and accurate; <br /> e. Name of Authorized A ent Print f.Si nature q. Date <br /> IV. ASBESTOS (Generator completes.IVa-f and Operator complete [Vg-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 the proper shipping name <br /> ,land are classified, packaged, marked and labeled/placarded, and are in all respects in proper condition for transport according to applicable international and <br /> tio,tional governmental regulations. <br /> g. Operator's Name and Title Print h. Signature i. Date <br /> *Operator refers to the company which awns, leases,operates,controls,or supervises the facility being demolished or renovated, or the demolition or <br /> renovation operation or both <br /> REV 01A4 TRANSPORTER RETAIN RS-F11A <br />