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I <br /> REPUBLIC' NON-HAZARDOUS SPECIAL WASTE & ASBESTOS MANIFEST <br /> /—� SERVICES <br /> I <br /> J I <br /> If waste is asbestos waste,complete Sections I, fl, III and IV <br /> y ¢ ,F' ti� �I If waste is NOT asbestos waste,complete Sections 1, II and III <br /> GENERATOR (Generator completes la-r) <br /> a.Generator's US EPA ID Number b. Manifest Document Number C. Page 1 of <br /> d. GenergWi tlFFt t9t' isPi�tsct tM9ttt, e. Generator's,MpIlang 6051{��s ti1]t ttt ti I--- <br /> ?IN <br /> ?IN Arch-AiTort Rd Ste ICY-) :1' W Arch411aport St Stet 13 <br /> 3J..Qttltftirl,CA 9,d ' 2YJtf-7343Q4 Sttx ktcri,CA Wi2M 20fi-Z34-34b4 <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.: <br /> j.Waste Profile# k. Exp. Date I.Waste Shipping Name and m.Containers n.Total o. Unit <br /> Description No. Type Quantity Wt1Vol <br /> 4204Y8139 i:� ;;T et metan{^ vad r i tt&irt+reatt€br tra <br /> i <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 condif oiti€or 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'n accordance with the requirements of 40 CFR 268 and is <br /> }no longer a hazardous waste as defined by 40 CFR 261. <br /> Generator Authorized Agent Name(Print) q. Signature r. Date <br /> �. TRANSPORTER Generator completes Ila-b and Transporter completes IIc-e <br /> a.Transporter's Name and Address: <br /> E <br /> b. Phone: <br /> c. Driver Name Print d. Signature e. Date <br /> M <br /> III. DESTINATION (Generator complete IIIa-c and Destination Site completes IIId-g) <br /> a. Dispo$af i1(ty_g,4§ite Address: c. US EPA Number d. Discrepancy Indication Space: <br /> Aatsfin Rd. <br /> Wnlwa,CA%336 A)O-t <br /> b. <br /> I hereby certify that the above named material has been accepted and to the best of my knowledge the foreqoinq is true and accurate. <br /> e. Name of Authorized Agent Print f. Si nature a. 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 /> i <br /> b. Phone: d. Phone: f <br /> e. Special Handling Instructions and Additional Information: <br /> I <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 /> ?nd are classified, packaged, marked and labeledtplacarded,and are in all respects in proper condition for transport according to applicable international and <br /> Zational governmental regulations. <br /> s <br /> 9. <br /> Operator's Name and Title Print 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 i <br /> renovation operation or both <br /> i <br /> I <br /> REV 01/14 RETURN TO OPERATOR RS-F11A <br /> I ' <br />