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TT REPUBLIC NON-HAZARDOUS SPECIAL WASTE & ASBESTOS MANIFEST <br />SERVICES <br />11c .709 If waste is asbestos waste, complete Sections I. II. III and IV <br />If waste is NOT asbestos waste, complete Sections I, I and ill <br />GENERATOR (Generator completes la-r) <br />a. Generator's US EPA ID Number <br />NIA <br /> <br />b Manifest Document Number c. Page 1 of <br />o kaenerator s Name and Location: <br /> <br />Vara North America . 2336 West Washington Street <br /> <br />f. gleifilPR CA 96203 918-376411:1 <br />e. Generator's Mailing Address- <br />Vara North Arneita <br />2K6 West Washington Street <br />. pfit*ton. CA 96203 916-376-6111 <br />If owner of the generating facility differs from the generator, provide: <br />h. Owner's Name i. Owner's Phone No. <br />j. VVaste Profile # k. Exp. Date <br /> <br /> Description <br />I. Waste Shipping Name and m. Containers n. Total i 0 Unit <br />No. Type <br />42042123119 2,22022 Soil E-47 <br />Quantity <br />1 ,./212 <br />GENERATOR'S CERTIFICATION: I hereby certify that the above named material is not a hazardous waste <br />state law, has been property described, classified and packaged, and is in proper condition for transportation <br />waste is a treatment residue of a previously restricted hazardous waste subject to the Land Disposal Restrictions <br />been treated in accordance with the requirements of 40 CFR 268 and is no longer a hazardous waste as defined <br />as defined <br />according <br />I certify <br />by 40 <br />by 40 CFR 261 or any applicable , <br />to applicable regulations: AND, if this I <br />and warrant that the waste has <br />CFR 261 , <br />11 E / Af-44 <br />4AaP Y•1:1-44 I • ( <br />14-ft-2,0- ro i_r) 44.0...•_,,.; ,\ <br />p. Generator Authorized Agent Name (Print) a. Sianature <br />• <br />RAIJ <br />c. Driver Name (Print) i <br />111. <br />b' CA. CA. 98336 209-9E12-4298 1 <br />a. Disposal =a and Site Address: I c. US EPA Number I d. Discrepancy Indication Space. <br />I hereby certify that the above named material has been accepted and to the best of my knowledge the foresoing-isAzi.ie and ac:curate. <br /><-2*.N-'. .,,,,___.,--:-;'., ''' PI/ <br />9999 S.Aiistin Rd. <br />Forward,. <br />DESTINATION (Generator complete lila-c and Destination Site completes IIId-g) <br />! <br /> ! <br />%--..-----"F <br />e. Name of AuthorizedAgent (Print)" I f Signature-- • . g 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 />TRANSPORTER (Generator completes ha-b and Transporter completes 11c-e) <br />a Transporter's Name and Address' <br />On 4/ Nom er)1 40.:, i'2 63 Zoe, Pe-Pt <br />b. Phone: "AtiweLizi:r. 1-4 '4'5 <512?- Ate7h- q / 176,e <br />ci.-Signatur <br />hder SA 5; 7.40Z-/ <br />e. Date <br />b Phone: d. Phone <br />e Special Handling Instructions and Additional Information: <br />f. 0 Friable 0 Non-Friable 0 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 />and are classtfied, 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 />g. Operator's Name and Title tPrint) I h. Signature Date <br />'Operator refers to the company which owns, leases, operates, controls, or supervises the facility being demolished or renovated, or the demolition or renovation operation or both <br />DESTINATION RETURN