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enera or completes a perator <br />a Operator's Name and Address I c Responsible Agency Name and Address <br />b Phone d Phone <br /> <br />e Special Handling Instructions and Additional Information. <br />f Li Friable CI Non-Friable El Both °A 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 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 />mplete IVg-i) <br />crry REPUBLIC NON-HAZARDOUS SPECIAL WASTE & ASBESTOS MANIFEST <br />ti4 seRrtrrs <br />1992634 <br />GENERATOR (Generator completes la•r) <br />If wacle rc achoctos witch, r ompintn Ser.tionc I II III and IV <br />It w.lcie Is NOT rtsbestie, waste nitirtele Sections I II diril III <br />c Page I of a Generator s US EPA in Number <br />MIA <br />b Manifest Document N111111101' <br />Genmalc, s Name and Locatoil Generator's Mailing Address <br />J11' Trarworlation, Inc JIL Tmnsportntion, Inc <br />38 01424 N, -121 21453 W, S13 liWYb <br /> <br />1015 Montngua Exproeswoy <br />1 Phone Q <br /> <br />Phone • 200-848-8060 <br />If owner of the oeneralPig <br />h Owner s Name i <br />facility differs from the generator, provide <br />i Owners Phone No <br />I waste Profile C ..... k. Exp Dale I. Waste Shipping Name and <br />Description <br />m Containers n. Total <br />Quantity <br />Unit <br />WUVol No Type <br />4204222536 2/14/2023 Soil I <br />WV /14 <br />1 <br />GENERATOR'S CERTIFICATION: I hereby certify that the above named mater s not a hazardous waste as defined by 40 CFR 261 or any applicable <br />slate law. has been properly described, classified and packaged, and is in p t • : condition for transportation according to applicable regulations: AND. if this <br />waste is a treatment residue of a previously restricted hazardous waste •• - 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 a d • onger a hazardous fa3.ste-gs—defined by 40 CFR 261 <br />l v . <br />V. re L. <br />L ( <br />! ( I r D3 p Gneralor Authorized Agent ame (Print) <br />•• -- - - - - - - - -- <br />---•••\..........., <br />It tF'ANSPORTER (Generator comple Transporter completes 11c-e) <br />a Transpoder's Name and Address f' i L G--3u sc-v(A4 <br /> <br />(ovecOuu414o ( 5-6s ,pli,dso,f? rLD <br />C Dnver N (Prin d nature 1".4 e Date /1 •-• <br />DESTINA ION (Generator complete Illa c and Destination Site m I - <br />a D polaggyan. iite Address <br />Manleca, C. 9633Cy AX4-a12-4298 b <br />MlaS <br /> <br />Au n Rd <br />c US EPA Number <br />t <br />d Discrepancy Indication Space <br />I here certif that I e abo - na d,matenal has been acce• ed and I kir ray kno edge the foregoing is true a <br />Er (---\ <br />a c.qa <br />e. Name of Authorized Agen Print) <br />_ __--- f. Sign tur/e x , g Dale <br />Operators Name and Title (Print) h Sionature Cat,, <br /> <br />'Operator refers to the company which owns, leases. operates. contro's or sup'ervises tne fa='•tir beng ce —c -s-ed rerova'er: cr renovation operation or both <br />-i•Et. 04,19 DESTINATION RETURN <br />CamScanner