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q'-. KREPUBLIC
<br />SERMES
<br />�.IL
<br />NON -HAZARDOUS SPECIAL WASTE &ASBESTOS MANIFEST
<br />If waste is asbestos waste, complete Sections 1, 11, III and IV
<br />It waste is NOT asbestos waste, complete Sections 1, II and III
<br />(. GENE`RATOR (Generator completes la -r)
<br />a. Generators US EPA ID Number
<br />b. Manifest Document Number
<br />r,. Page 1 of
<br />d. Generator's Name and Location:
<br />e. Generator's Melling Address:
<br />Port ofStoc:.kon i PT m4atyra&nett;,:
<br />waSt'tingtoi1 �Jt.
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<br />,ttxk; wel, CA 9!PG1j
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<br />rti Cori
<br />f. Phone `fara t3?.1ix�a tt.•t•tfstI
<br />g, Phone:
<br />b.
<br />If owner of the generating facility differs from the generator, provide:
<br />h. Owner's Name:` ti`'c}r'++ of `;;ocktort
<br />i. Owner's Phone No!.G9I,;;94;-ts'.7g6
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<br />j. Waste Profile #
<br />k. Exp, Date
<br />1. Waste Shipping Name and
<br />m. Containers
<br />n. Total
<br />o. Unit
<br />has been
<br />acre'
<br />Description
<br />Quantic
<br />Wt/Vol
<br />No.
<br />Type
<br />by the proper shipping name
<br />and are classified, packaged, marked and labeled/placarded, and are in all
<br />respects in proper condition for transport according to
<br />applicable international and
<br />national governmental regulations.
<br />+�tto�iMr27� For
<br />ti3'iiSl+(1t+?
<br />e. Name if AUthorIzed`A enf Print
<br />BA
<br />I'. Sf
<br />YE;
<br />Q. Date
<br />g. Ob erator'b Name and Title
<br />Print
<br />h. Signature
<br />1. Date'
<br />yt
<br />'Operator refers to the company which owns, leases, operates, controls, or
<br />supervises the facility being demolished or renovated,
<br />or the demolition or
<br />renovation operation or both
<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 CFP. 268 and is no longer a hazardous waste as defined by 40 CFR 261.
<br />Generator Authorized Agent Name (Print)
<br />q. Signal re
<br />r. Date
<br />a. Transporter's Name and Address,
<br />j(•��rst 0fit4=1=„ t.l=t�s�F.1> r a.�f` 5 N Firip.Yl d Awl iue
<br />b. Phone:
<br />L.c,`flfiver 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 />r,ttIMhfrf'} tnraDr
<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 />C'ilit r;t ati:+Ciir:Giri :gni ft
<br />V
<br />tLlr tri+~.,
<br />?C7 "r+,r+r 3sp
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<br />'_a3".T?'i AU ITIN RQAf}, f lj\NTF,t L-,
<br />t: -.r wsiis
<br />1IWA.: o %. *:< t = c• to R a
<br />b.
<br />d. Phone:
<br />e. Special Handling instructions and Additional Information:
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<br />b4
<br />RIB tit i ji�C
<br />B ERI. 15Iw 16
<br />If
<br />)i herebcertif that the above named material
<br />has been
<br />acre'
<br />tod and to the best of m
<br />knowied
<br />a the fore Din is true:bnd accurate. j
<br />OPERATOR'S CERTIFICATION: I hereby declare that the contents of this
<br />consignment are fully and accurately described above
<br />by the proper shipping name
<br />and are classified, packaged, marked and labeled/placarded, and are in all
<br />respects in proper condition for transport according to
<br />applicable international and
<br />national governmental regulations.
<br />e. Name if AUthorIzed`A enf Print
<br />I'. Sf
<br />nature ` 1
<br />Q. Date
<br />g. Ob erator'b Name and Title
<br />Print
<br />h. Signature
<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 />C'ilit r;t ati:+Ciir:Giri :gni ft
<br />V
<br />Rev Dura GENERATOR RETAIN Rs-F»A
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<br />.Yerlt:iStL'ii,r„i
<br />t: -.r wsiis
<br />b.
<br />d. Phone:
<br />e. Special Handling instructions and Additional Information:
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<br />tS t. i
<br />q 1 llwi =.+1ST, MC+Os:1'ii}, C g7,'-,n£Z, It)". z4 ,06 is l_
<br />1 .
<br />RIB tit i ji�C
<br />B ERI. 15Iw 16
<br />f. ❑ Friable{
<br />tO Non -Friable D Both % Friable
<br />% Nan -Friable
<br />OPERATOR'S CERTIFICATION: I hereby declare that the contents of this
<br />consignment are fully and accurately described above
<br />by the proper shipping name
<br />and are classified, packaged, marked and labeled/placarded, and are in all
<br />respects in proper condition for transport according to
<br />applicable international and
<br />national governmental regulations.
<br />g. Ob erator'b Name and Title
<br />Print
<br />h. Signature
<br />1. Date'
<br />'Operator refers to the company which owns, leases, operates, controls, or
<br />supervises the facility being demolished or renovated,
<br />or the demolition or
<br />renovation operation or both
<br />Rev Dura GENERATOR RETAIN Rs-F»A
<br />
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