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NON -HAZARDOUS SPECIAL WASTE & ASBESTOS MANIFEST
<br />RA y ., y 1 *41
<br />If waste is asbestos waste, complete Sections I, Il, III and IV
<br />it waste is NOT asbestos waste, complete Sections I, II and III
<br />I, GENERATOR (Generator completes la -r)
<br />a. Generator US EPA ID Number
<br />I A
<br />b. Manifest Document Number
<br />NIA
<br />c. Page 1 of
<br />1
<br />%rtti,
<br />d. Generator's Name and Location:
<br />e. Generator's Mailing Address:
<br />Port,
<br />PC' Box 20,949
<br />!1.13 t7if year . Ave.
<br />tt�rr ;A is i'it
<br />r�c,rt rt, Cr 99'90-i
<br />707«S 51-7tsii7
<br />f. Phone: '1.''51"'70f'7
<br />g. Phone:
<br />,
<br />If owner of the generating facility differs from the generator, provide:
<br />i?S'i of et CS S. t{.141
<br />f t
<br />707.1s%1. *1007
<br />h. Owner's Name:
<br />I. Owner's Phone No.:
<br />j. Waste Profile #
<br />k. Exp. Date
<br />I. Waste Shipping Name and
<br />m. Containers
<br />I hereby certify that the above named material has
<br />n. Total
<br />o. Unit
<br />No.
<br />Type
<br />Description "'
<br />Quantity
<br />WWol '
<br />C2Ctttt! 12671
<br />1�ctf�rlar:. 111115
<br />NFon Fria hL>
<br />OPERATOR'S CERTIFICATION: I hereby declare that the contents of this
<br />Et✓�
<br />by the proper shipping name
<br />%4D
<br />respects in proper condition for transport according to
<br />applicable international and
<br />national governmental regulations.
<br />e. Name of Authorized A ent Print I
<br />f. Si
<br />nature
<br />. Date
<br />Operator's
<br />Name and Title Print
<br />h. Signature
<br />i. Date
<br />.
<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, orboth
<br />w
<br />7
<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 proRer 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 2614
<br />p. Generator Authorized Agent Name (Print)
<br />q. Signature =.
<br />r. Date
<br />TRANSPORTER (Generator completes Ila -b and Tray
<br />a. Transpgds 's ,dame and Address:
<br />y
<br />P 0:4 t_if:'WP2 i moi. Lt1 CJ . 1:rflip_t'r�W ✓r�t
<br />'�V"tie
<br />c. Driver Name Print d. Si nature � "'- '-��"" ` e. Date
<br />1113 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 />1=CrRiAri;ftt? tAN
<br />IV. ASBESTOS (Generator completes IVa -f and Operator' complete IVg-i)
<br />a. Operator's Name and Address:
<br />r
<br />REV , GENERATOR RETAIN t�?" RS4
<br />0111rr4AA
<br />c. Responsible Agency Name and Address:
<br />%rtti,
<br />PCt 90t 4ti35
<br />:111 ?iitt7t,ra:+vg
<br />Stttt:ktor, Ci 1?51CiL
<br />9c:gk) S. AUZJT lid t;i:1AD, it TAHI IL"A CA 95 D6
<br />797_cc
<br />,
<br />b. Phone:
<br />d. Phone:
<br />b:
<br />_
<br />r,
<br />.i �irf3 tLSft ikrtt, tl'�C., {'ci.8 rtiC/: �SS'S7�. �0§S, P'tG:a e�F.t1, �• 2. i:Q. _��i-47t7t;. �. �,
<br />ro notY,rJaat> Ga: s', hs,lru �i r Jf1LT7£ irr t: w {
<br />I hereby certify that the above named material has
<br />been
<br />accepted
<br />and to the tfest off
<br />-m knowledcle the forecioing is true and accurate. ;
<br />L ❑ Friable p •❑ Nan -Friable ❑ Both % Friable
<br />% Non -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 />e. Name of Authorized A ent Print I
<br />f. Si
<br />nature
<br />. Date
<br />IV. ASBESTOS (Generator completes IVa -f and Operator' complete IVg-i)
<br />a. Operator's Name and Address:
<br />r
<br />REV , GENERATOR RETAIN t�?" RS4
<br />0111rr4AA
<br />c. Responsible Agency Name and Address:
<br />P3=t, i�P �tDct;L:r,
<br />PCt 90t 4ti35
<br />:111 ?iitt7t,ra:+vg
<br />Stttt:ktor, Ci 1?51CiL
<br />atuclitwi, A ,'-•t
<br />797_cc
<br />f ... � i..7taC? 7
<br />b. Phone:
<br />d. Phone:
<br />e."Special Handling instructions and Additional Information:
<br />_
<br />r,
<br />.i �irf3 tLSft ikrtt, tl'�C., {'ci.8 rtiC/: �SS'S7�. �0§S, P'tG:a e�F.t1, �• 2. i:Q. _��i-47t7t;. �. �,
<br />ro notY,rJaat> Ga: s', hs,lru �i r Jf1LT7£ irr t: w {
<br />Jit $ i t�i'✓t f�R:��. }�i
<br />L ❑ Friable p •❑ Nan -Friable ❑ Both % Friable
<br />% Non -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 />Operator's
<br />Name and Title Print
<br />h. Signature
<br />i. Date
<br />.
<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, orboth
<br />w
<br />Fi lA
<br />d
<br />
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