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QRW REPUBLIC <br />114 SERVICES <br />3)`89462 <br />NON -HAZARDOUS SPECIAL WASTE & ASBESTOS MANIFEST <br />If waste is asbestos waste, complete Sections I, II, III and IV <br />If waste is NOT asbestos waste, complete Sections I, II and III <br />n�u�nATA15 .+ n1 -+e I—A <br />a. Generator's US EPA ID Number <br />inn <br />b. Manifest Document Number <br />c. Page 1 of <br />d. Generator's Name and Location: <br />e. Generator's Mailing Address: <br />.,:111' L I ,,I x. <br />"!' ', 1. 'jame <br />W78 E, Kettlemlan l9,., <br />8478 F Ketilem9n I_tule <br />f. Phone: t rYJ, CA 1 <br />g. Phone: A 4�,' <br />If owner of the generating facility differs from the generator, provide: <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 />n. Total <br />o. Unit <br />Description <br />No. <br />Type <br />Quanti <br />Wt/Vol <br />4204170369 <br />-- <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. 1 certify and warrant that the waste has <br />been treated in accordance with the requirements of 40 CFR 266 and is no longer a hazardous waste as defined by 40 CFR 261. <br />p. Generator Authorized Agent Name Print . Si na ure r. Date <br />11, 1 KPUVSrUK 1=N <br />a. Transporter's Name and Addi <br />W.-t+r,l`''i.I <br />k3eneratur cur]IurtZMjb nc--u C211U I <br />III nC0TIKIA'rI^k1 /r�­e #� nmmlafa IIh_r nnrl n#actinatinn �,itR rtr]rrinlPtas Illd-al <br />....--- -------- --- ,-- - - <br />a. Disposal Facility and Site Address: <br />t.w b Aynhra f•:cxui <br />b. <br />c. US EPA Number <br />d. Discrepancy Indication Space: <br />I herebycertifythat the above named material has been accepted and to the best of m knowledge the fore goingis true and accurate. <br />OPERATOR'S CERTIFICATION: 1 hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name; <br />and are classified, packaged, marked and labeled/placarded, and are in all respects in proper condition for transport according to applicable international and <br />national governmental regulations. <br />e. Name of Authorized Agent Print <br />f. Signature <br />q. Date <br />n/ w t10ocrnc ir-2--etnr r•mmnlatac I\/a-t and r ]nPrnTnr MMMP.TR. Ion -II <br />a Operator's Name and Address: <br />b. Phone: <br />c. Responsible Agency Name and Address: <br />d. Phone: <br />e. Special Handling Instructions and Additional Information: <br />f. ❑ Friable ❑ Non -Friable ❑ Both % Friable % Non -Friable <br />OPERATOR'S CERTIFICATION: 1 hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name; <br />and are classified, packaged, marked and labeled/placarded, and are in all respects in proper condition for transport according to applicable international and <br />national governmental regulations. <br />q. Operator's Name and Title Print h. Signature <br />I 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 />REV 01114 I RS-1`11ARETURN TO GENERATOR <br />