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Home My WebLink AboutPermit Demolition 2009-12-22 ..', If . - /; CITY OF ~rKINGFIELD Building/Combination Permit PERMIT NO: COM2009-01827 ISSUED: 12/22/2009 APPLIED: 12/22/2009 EXPIRES: 06/22/2010 VALUE: Status Issued 225 Fifth Street, Springfield, OR . 541-726-3753 Phone 541-726-3676 Fax 541-726-3769 Inspection Line SITE ADDRESS: 421 A ST ASSESSOR'S PARCEL NO.: 1703353105400 Springfield TYPE OF WORK: Site Work Only TYPE OF USE: Demolition Commercial PROJECT DESCRIPTION: Demolition and sanitary sewer cap Owner: MCKENZIE RIVER MOTORS INC Address: PO BOX 640 PLEASANT HILL OR 97455, I C:ONl'~AC~OR 1NFORMA,TlON I Contractor Type General Contractor STANTON GREGORY P A Yi'\TE c License 27323 Expiration Date 05/0912010 Phone 541-688-7038 - I BUlLDING,IN~ORMATlONI # of Units: ' # of Stories: 011 to Primary Occupancy Group: goo \a'M~re\t\\lF Secondary Occupancy GrolQ't'ENT\ON: OTe ted PY"'!E'~~t ,Olth Primary Construction TYIiOIIOIN ~\e9 a~~~T. l\lOllllfl52-OO'O Secondary Construction TPllltili. ,cation ~,-oo'ot,,~g e ~es bY # of Bedrooms: In OAR 952 ay obtain c. Bf6f>hOne 0090.. 't'~~ centeT. (NQ\lli 'ROl"~\\ n/a -:Ul"ft"IV :If'rn 1n ' .\ ' ri\lmb8":n~~rlliq~iNFORMATlON I Lot Size: Sq Ft 1st Floor: Sq Ft 2nd Floor: Sq Ft Basement: Sq Ft Garage/Carport Sq Ft Other: Occupant Load: . Front yard Setback: Side 1 Setback: Side 2 Setback: Rearyard Setback: Solar Setbacks: Overlay D~,~;. .,.,", # Street Trees Rqd: Paved Drive Rqd: % of Lot Coverage: REQUIRED PARKING Total: Handicapped: Compact: Street Improvements: Storm Sewer Available: Sl'ecial1ustruetion: 1 PU,BLICIMPROVEMENTS I .. .Sidewalk,Type:",...." NOTICE:' ','.: ::,.' ~~lwi"F~~J\lJQl.BK , THIS PERMIT SH~~~ ~HIS PERMIT \S NOT ~, AUTHORIZED UN IS ^B^NDONED FOR ,< COMMENCED OR "" .' t "\. .pl} n ^v Dl=l'llon. -- , . 1-.... . J_ - I Valuation Descriqtion I Notes: Description Type of Constructi?" $ Per Sq Ft or multiplier Square Footage or Bid Amount Value Date Calculated Pa2e 1 of 2 .,~' CITY OF SPRINGFIELD Building/Combination Permit PERMIT NO: COM2009-01827 ISSUED: 12/22/2009 APPLIED: 12/22/2009 EXPIRES: 06/22/2010 VALUE: Status Iss u ed 225 Fifth Street, Springfield, OR 541-726-3753 Phone 541-726-3676 Fax 541-726-3769 1nspectionLine Total Value of Project Fees Paid I '" , "11 Fee D'escription + 12% State Surcharge + 5% Technology Fee Demolition Sanitary or Storm Sewer Cap Amount Paid Date Paid Receipt Number $13.92 $8.70 $58.00 $116.00 12122/09 f2/22/09 12/22/09 12/22109 1200900000000001354 1200900000000001354 1200900000000001354 1200900000000001354 Total Amount Paid $196.62 Plan Reviews I ~ . '.- 'I. To Request an inspection call the 24 hour recording at 726-3769. All inspections requested before 7:00 a.m. will be made the same working day; inspections requested after 7:00 a.m. will be made the following work day. Reollired Insnections I Demolition: After demolition is complete, sewer is capped or septic is pumped and tilled and inspection is requested and approved, and all debris is removed from Ihe site. I Sanitary Sewer Cap: Capped within live (5) feet of the property line and capped with an approved material as required by the- code. ,. . By signature, I state and agree, that I have carefully examined the completed application and do hereby certify thai all information hereon is true and correct, and I further certify that any and all work performed shall be done in accordance with the Ordinances'of the City of Springfield and the Laws of the State of Oregon pertaining to the work described herein, and that NO OCCUPANCY will be made of any structure without permission of the Community Services Division, Building Safety. I further certify that only contractors and employees who are in compliance with ORS 701.005 will be used on this project. I further agree to ensure that all required inspections are requested at the proper time, that each address is readable from the street, that the permit card is located at the front of the property, and the approved set of plans will remain on the site at all times during construction. A _/7~~ /;)-;}d--o? ~ , . /"'" . Owner or Contractors Signature Date Page 2 of 2 225 Fifth Street Springfield, Oregon 97477 541-726-3759 Phone Job/Journal Number COM2009-0 1827 COM2009-0 1827 COM2009-0 1827 COM2009-0 1827 Payments: Type of Payment Check cReceintl RECEIPT #: Description Demolition Sanitary or Storm Sewer Cap + 5% Technology Fee + 12% State Surcharge Paid By GREG PAYNE BRENDA PA YNE City of Springfield Official Receipt Development Services Department Public Works Department 1200900000000001354 Date: 12/22/2009 Item Total: Check Number Authorization Received By Batch Number Number How Received djb 50711 In Person Payment Total: .' .~. Page 1 ofl 2:39:00PM Amount Due 58.00 116.00 8.70 13.92 $196.62 Amount Paid $196.62 $196.62 12/22/2009 !"'PRINGFIELD :..~.! ~~/": ",-"" , ~~'..... A!..', .:;;F^-'~~"..~ ........ .DEMOLITION PERMIT APPLICATIONS Your demolition permit is currently being processed. 'There may be a slight delay, of up to 2 working days for small structures, due to the time required to review the history of the structure to determine if it needs to be documented before demolition. This documentation is for ar'~IiiYW.!J',un>6ses,dp.ly:ana'~lhlO(lj.ffect the granting of the demolition permit. If the structure is very large or complicated the documentation process may take up to a maximum of 4 working days. Documentation will consist of photographing the building, taking measurements and making scaled drawings. The documentation will be undertaken by the City at no cost to you. Documentation is being done on all structures dated prior to 1940 that may . have historic importance to the City's development. THIS DOCUMENTATION WILL NOT IMPEDE THE DEMOLITION PROCESS. An age cut-off of 1940 was chosen because this is the date that the National Parks Service and The Springfield Development Code use to determine potential historic significance. If you would prefer to complete this documentation yourself you must provide the City with the following information: 1) black and white photographs of each elevation, a floor plan with measurements, and 2) a set of elevation drawings with measurements. Thank you for your patience. I grant the City of Springfield permission to enter my property to complete documentation prior to the requested demolition of the structure located at: Address: .J/::21 AJ",."J,l - ,-4<:;~_uJ. ... Property Owner Signature: ~_._~ JobNumber: r-o""'zoo~- OCE'Z-7 Date: /..2. -/S-d 9 ~ ~d n ,_c ",-c - ~ '_ ," _ ~~, " - '." ," ,', ;: \". "t'-,JJIT:W~QE-S:RRINGfIEFffD o RiEGO!l:'lt'- , ':,1,' ,.Ii,' "'''^' c,' \ '#..0.....(- ,,*1<i"i".~ .';;mSL t~~ ~1'!~ ~'-it^t '" WSii'ffili- ~, ,~::~ :b:"" &~l ~'\;; ~'ii + ~ ~_ Ii """",' .J:'~'... ".a:",A> ,,= ~~~ '!\W-.. """",-"" '" ~C,,-<q "" "Gtwt W ~ ,""_- "_~ ~~_ 1,0 SPRINGFIELD 225 FIFTH STREET - SPRINGFIELD, OR 97477 - PH:(541)726-3753 -FAX: (541)726-3689 DEMOLITION PERMIT APPLICATION . lit/., Address: ,';) I J/ ~'J.~~ /,3vAJJ;,1i) /3 VII! S~~ !!I-IJ IJ 5~AJ J1 Structure to be Demolished: (e>n.-,,,........ id'.,'/11 1!0,.J,j,'ng / Job Number: COM Zoo C; - c) I g> Z. ~ The applicant is hereby notified that any redevelopment of the subject site must comply with all of the applicable laws, codes, ordinances, polices and plans in effect at the time the redevelopment proposal is accepted as complete for City review. This would include correction of substandard conditions associated with the present development. Examples of such corrections may include modification of inadequate drainage facilities; compliance with building set, backs from property lines; correction of substandard sidewalks and street improvements, including driveway width and placement; and other corrections which may be necessary to comply with existing development standards. Furthermore, if an existing use is demolished or otherwise removed prior to the development of the proposed use, then the system development charge credit for the previously existing use shall expire two years after the date of issuance of the , demolition permit or other removal of the previously existing use. (Springfield Municipal Code 3.416(1)). My signature below indicates that I have read and understand the above conditions relating to the demolition of the above mentioned structure. Sif~~~_~~l~ J;2-/?-tJ7 Date .... . '..\ , ..- ~,,~ ~ (J , .._. <.::. J _ -.. ~ C~, S J"h\(:) ..J Dee OS OS 01:15p LaM-ZOO 9 - 0 f 8" 2. -,. p.2 .' aAl' . . E(;:o~~~ 9'\, / "';Y~'IIIIl''>'''~''fMt''''''fcOI.uI(l.'' ...... ." ..""". ~ .IL"-,\,. A VERIFIED SERVICE-D4SABLEiJ VETERAN-OWNED HUB.ZONEO SMALL BUSINESS Environmental Remediation _ Asbestos/lead/Mold/Drug labs/PCBs/Heat & Moisture Detection/C02 Dry Ice Blasting .A COMMITMENT TO EXCELLENCE 23525 Hwy. 99 E. Harrisburg, OR 97446 cce #64090 PH 541-995-6008 FX 541-995-1015 Email atezla>atezinc.com Website www.atezinc.com _. ...... k', PROJECT COMPLETION NOTIFICATION ASBESTOS Date: 11/25/2009 ATEZ, Inc. Project ControLl'!lll])~r: 091001 Client: Ms. Sue Wright CDC 1.01 E Broadway #103 Eugene, OR 97401 Project: Remove asbestos containing: Trans~e, Mastic, Floor Tile, Caulking, Silver Coat, and Vibration Dampener Commercial Structure N 5th and A Street Springfield, OR ", Attention: Ms. Wright Attached please find all the documentation pertaining to the proper removal and disposal of: 421 NORTH 'A' ROOF I. FOUR THOUSAND square feet (4,000 SF) of asbestos-containing Silver RDOf Coat on . roofing, and; 2. All HVAC Ducts with asbestos-containing Silver Roof Coat, and; 3. 2-Each (02 EA) asbestos-containing HVAC Vibration Dampeners 4. ONE HUNDRED SIXTY lineal feet (160 LF) of asbestos-containing Silver Roof Coat on parapet cap, and; EXTERIOR 5. 'TWENTY-FIVE lineal feet (25 LF) of asbestos-containing Grey Caulking, and; 6. SEVEN lineal feet (07 LF) of asbestos-containing WMe Window Glazing, and; 7. 'TWENTY-FIVE lineal feet (25 LF) of asbestos-containing Tan Window Frarne Caulking, and 130 NORTH 5"' STREET 8. 1-Each (01 EA) ceiling hung Gas Heater with asbestos-containing sealant, and; 9. THREE THOUSAND FIVE HUNDRED square feet (3,500 SF) of asbestos-containing Tan g"Xg" Floor Tile, and; I <1 Dee OS OS 01:15p SCOPE. OF WORK (Cont'd): . 134 NORTH 5th STREET p.3 10, TWO HUNDRED square feet (200 SF) of asbestos"containing Green 9"X9" Floor Tile, and; . 140 NORTH 5th STREET 11. TEN square feet (10 SF) of asbestos-containing White Millboard, and; 12. TEN square feet (10 SF) of asbestos-containing White Floor Tile, and; EIGHT HUNDRED FIFTY-SIX square feet (856 SF) of asbestos-containing Green 9"X9" Floor Tile. and; 13. ONE THOUSAND SIX HUNDRED SIXTY square feet (1,660 SF) of asbestos-containing Multi-Color Brown 9"X9" Floor Tile, and; TWENTY square feet (20 SF) Df asbestos-containing White Sheet Vinyl, and; 14. ONE HUNDRED THIRTY square feet (130 SF) of asbestos-containing Light Tan S"XS" Floor Tile, and; 15. ONE THOUSAND THREE HUNDRED SIXTY square feet (1,360 SF) of asbestos- containing Dark Tan S"XS" Floor Tile, and; 427 NORTH 'A' STREET 16. EIGHTY square feet (80 SF) of asbestos-containing Grey S"XS" Floor Tile, and; 421 NORTH 'A' STREET 17. TWO THOUSAND EIGHT HUNDRED square feet (2,800 SF) of wood paneling with asbestos-containing Mastic, and; 18. THREE HUNDRED TWENTY square feet (320 SF) of asbestos-containing Dark Brown 9"X9" Floor Tile, and; . 'H. ONE HUNDRED square feet (100 SF) of asbestos-containing Roofing Debris, and; 20. SIX HUNDRED NINETY square feet (6S0 SF) of asbestos-containing Green Sheet Vinyl, and.' ' . , 21. SIX HUNDRED NINETY square feet (6S0 SF) of asbestos-containing Tan9"X9" Floor Tile, and; STORAGE AREA 22. 1-Each Steel Framed Window (01 EA) with THIRTY lineal feet (30 LF) of asbestos- containing Glazing This Work. will be completed as a Class I & II, Friable & Non-Friable, Full-Scale, Non-Prevailing Wage, Commercial Pre-Demolition LRAPA Asbestos Abatementproject. A TEl, Inc. removed and estimated 19,000 SF of mastic on the concrete slab-on-grade and 200 square feet of asbestos containing transite roofing/sidewall panels. If additional hidden asbestos containing materials are uncovered during the renovation/demolition process you must cease work and contact an asbestos abatement contractor to properly remove and dispose of the additional materials per DEO, LRAPA and EPA regulations. The work was completed on 11/24/0S by a certified asbestos abatement supervisor and certified asbestos abatement workers. The work was completed without incident in compliance with EPA, DEQ/LRAPA regulations. 2 Dee OS OS 01:15p p.4 . The waste is being stored at 23525 Hwy 99 E Harrisburg, Oregon until it is transported under cover to Coffin Butte Landfill for disposal. At that time, you will receive an ASN-4 form showing the waste . was disposed of in compliance with appropriate regulations. Included under this same cover, please find copies of the LRAPA Notices. Contractor's License and Employee Certifications, Air Monitoring results. and ASN-4 (disposal document).., If any further information is required please call our office at 541-995-6008. Thank you. a)/,~ . eU~ .~&, ~'--- -- .7 Robert R Kiny6l1: ~TEZ, Inc. 3 . STATE OF OREGON CONSTRUCTION CONTRACTORS BOARD. LICENSE CERTIFICA TE t:l ro n o '" o '" o LICENSE NUMBER: 64090 ~ .. ~ This document certifies that: ATEZ INC 23525 HIGHWAY 99 E HARRISBURG OR 97446 en "lI is licensed in accordance with Oregon law as a Residential General Contractor and a Commercial General Contractor level 1. License Details: EXPIRATION DATE: 02102/2011 ENTITY TYPE: Corporation INDEP. CONT. STATUS: NONEXEMPT RESIDENTIAL BOND: $20,000 COMMERCIAL BOND: $75,000 INSURANCE: $4,000,0001 $4,000,000 RMI: ROBERT R KINYON HOME INSPECTOR CERTIFIED: NO LEAD BAsED PAINT LICENSED: YES "lI (JJ Dee 09 09 Ot:16p p.6 ~ ~ ~ FULL SCALE ASBESTOS ABATEMENT CONTRACTOR LICENSE Department of Environmenta] Quality 1550 N,W. Eastman Parkway, Suite 290 Gresham, OR 97030 . Telephone: (503) 667-8414 ex!. 55022 Issued in Accordance with the Provisions ofORS 468f.,710 ISSUED TO: LICENSE NUi\1:BER: AIEZ INC 23525 HWY 99 E HARRISBURG OR 97446 FSC535 EXPIRATION DATE: MARCH 1,2010 INFORMATION RELIED UPON: Asbestos Abatement Contractor License Application submitted JANUARY 20, 2009 ISSUED BY THE DEPARTMENT OF ENVIRONMENTAL QUALITY ~L. Ed Oruback Ai-rQuality Manager Northwest Region/Gresham Office .JAN 2 S 2009 Date . I The contractor named above is herewith authorized to conduct asbestos abatement in the State of Oregon subject to the terms and conditions of Oregon Administrative Rules (OAR) Chapter 340 Division 248, including the conditions listed below. 1. The contractor shall ensure that each worker performs asbestos abatement work in compliance with OAR 340-248-00]0 through 340-248-0290 and other appii~able state and federal asbestos abatement regulations. Dee OS OS 01:16p p.? "______u____==-___ _ . _ _ __~ ____. _ _ __ _ . TEN-DAY AND NON-FRIABLE NOTIFICATION OF INTENT TO REMOVE OR ENCAPSULATE ASBESTOS IN LANE COUNTY, OREGON Lane Resional Air Protection Agency 1010 Main Street sprinllfield, OR 97477 '. .__~_.J5~1)!36.1056.!a>t: (~~1)!26.1~05. tollfre.elB~~) 2B~.727.2 . Type of Abatement Project Category and REQUIRED Fee il( Demolition c Emergency Waiver !Add'50'1l\ to required fee) S o Removal S 46 0 Non-Friable (5-Day Notice) o Encapsulation S 46 c Residential Project (Occupied Residence, !!!!! for Demolition) o Renovation $ 46 c ~ 40 lin/SO sq ft (Small Scale, Short Duration) o Maintenance/Repair S 98 c > 40 linear/SO square feet; ~ 260 IInear/l60 square feet Other_ S 394 0 > 260 linear/160 sqft; ~ 1,300 llnear/800 sqft S494 c 'l,300linear/800sqft;~2,600linear/1,600sqft S 855 0 > 2,600 linear/1,600 sqft; ~ 5,000 linear/3.500 sqft S 986 IX > 5,000 IInear/3.500 sqft; ~ 10,000 linear/6,ooo sqft S 1,579 c > 10,000 linear/6,OOO sqft; ~ 26,000 linear/16,ooo sqft $ 2,632 0 > 26,000 linear/16,000 sqft; ~ 260,000 linear/16D,ooO sqft S 3,290 c ~ 260000 linear/l60000 sqft ,.,i}~._.~.J.~~ For LRAPA Use: ItFI- ~ . Project: .'Fee Rec'd: S Check #: /fYes Has a survey been completed? Yes'i( No D By WhOm?~7 . Is this a revtslon to a DreYious notlficatlon? - Yes 0 No c <ABATEMENT"OJECTINFORMATlON U _U - U _uu. -. .-.----- -- -- - --..- i SiteNameL:~~'ld\"-t>~( ~..~,~.~ . Phone , ' ';.., , . , SiteAddress p=.&t\~ '.Jild \ . Clty"5'.ffll-nQ~uv.bJ ~ I location of Asbestos at the site VI.."..", ~ . nA.- ,,,.I r^,~.~^, ' ) I Site Category: 0 school 0 residence 0 coHege .0 irKjustrial 0 commercial ,.j' other ; Start Date 10-'1.-0<1 Completion Date-J/l::./f ::!l1Hours on Site ~~~ Days on Site' -' I Emergency project notiftcation requested: D No 0 Yes -- DIscussed with Date I TYPE OF ASBESTOS MATERIAL __ , Type!'t Percent of Asbestos jnl" ('!~~A. L.... 0 EstimateXLab ,j __ Quantity of asbestos in project --.\r-'~ ~ 0 linear )i.Square c Cubicfeet . i ,. c pipe insulation otape 0 cementatious(fg: transite) 0 floor tile 0 rORfing 0 felt 0 sprayon o valve packing 0 mastic b( sheet vinyl l( other "'" 1 I. tM C.<xJr,l' llo--a J-u"1 o;.....~ ' WORK PRACTICES AND REMOVAL PROCEDURES , )I.wet method - 0 dry methods with air filtering .0 glovebag Jltcontainment ~negative air ')ioHEPA vacuum 0 vacuum truck with HEPA filter 0 other Ambient air monitoring to be performed: ~yes 0 no I DISPOSAL PROCEDURES . I 0 chute to drop box 0 hand-load dropbox )(, wetted and double bagged iK other...& ~ -b::> ! 0 waste stored on site In secured container 0 waste secured off site at c waste. _,.... _~ daily 0 other DISPOSAl SITE " . XS_hO~~IJntain _" Coffin B_utte \"J'~!" _ ABATEMENTCONTRA~TOR -C"7 orl" . - .- .---- , Contractor Name L ~ . "J-J1 1'.... license No. F S G. 535 , Mailing dress - :t. rJn 'Ie . / ~ . , City ar ' State.o Fe ZIP~ Phone ?"t't -"'?'?7 -~,ls' Competent Person Certificate No. .~/j.'1 1-' Cell/Pager No.<"'i'>i_. ,L,';:'y -- PR:;~TY~~N~fYi M.)<~, "i,. 'Lkc.bUuLc111ud31 5iP7/ cSt-X) . Maili,gg Address ir\l' f' v.v."",,(l. ".' i _ .fL fn~ CitY~f-' . . -'. Stattle1l ilP91liol Phone~!. --:l,(;(-~! N.ame(Pteasep;JPt9llL)b~J6I?1tf! 'lrganiution A-IE;:. I1"l0, Slgnatur" ~/~rv'., ,.4:- ~ PhonE' .1f#t/"'lq,?bt:JO'ir Email ,;/"...,.......--- ./ ' , - f)"t.. "1'-7,?-<,'F> - - - - - -. - ..l--~ -- ~ I ----;1 Form Available on LRAPA website: www.lrapa.org Asb:070109 Dee OS OS 01:17p p.8 ~/ ___ _ _ __ _u__ ____ __ __ "_ __=-===--_ TEN-DAY AND NON.FRlABLE NOTIfiCATION OF INTENT TO REMOVE OR ENCAPSULATE ASBESTOS IN LANE COUNTY, OREGON Lane Regional Air Protection Agency 1010 Main Street Springfield, OR 97477 _ .. _ j5~I)J~~-_1.!l5_6~ ~~: 1~411 ~~6-_12~5,--toll free IB7~1 ~~5_-!_2?~ _ _._ .. Type of Abatement Project Category and REQUIRED Fee \)( Demolition 0 EmergencY Waiver lAdd 5O'.l> to required fee) ~ o Removal S 46 \)( Non-Friable (5-Day Notice) o Encapsulation S 46 0 Residential Project (Occupied Residence, !!!!! for Demolition) o Renovation S 46 0 ~ 40 lfn/BO sq ft (Small Scale, Short Duration)' o Maintenance/Repair S 98 0 > 40 linear/80 square feet; ~ 260 linear/16O square feet Other_ S 394 0 > 260 linear/160 sqft; ~ 1,300 linear/800 sqft S 494 0 > 1,300 linear/BOO sqft; ~ 2,600 linear/I ,600 sqft S 855 0 > 2,600 linear/l,6oo sqft; ~ 5,000 linear/3,5oo.sqft S 986 0 > 5,000 linear/3,500 sqft; ~ 10,000 linear/6,OOO sqft S 1,579 0 > 10,000 linear/6,OOOsqft; ~ 26,000 linear/16,ooo sqft S 2,632 0 > 26,000 linear/16,OOO sqft; ~ 260,000 linear/160,OOO sqft S 3,290 0 ~ 260000linear/l60000 sqft - ;_._"--~J For LRAPA Use: L - . Project: '-Fee Rec'd: S Check #: __ ._ _____ I i IIYes Has a survey been completed? Ye"X No 0 By aT;"") Jo-IL, WhOm?~. Is this a revision to a previous notification? Yes:o No':r/ i- ABATEMENT ~~TINf6RMATIO,N-'::"--- ~._. . Site Name 'r)J'APi" \.4. \'f;L" ~~.(" Phone _' (1 : Site Addressj,5i .... ~ ~ L li1..l . J'-W1i1..;p- I,"i1. <nii? City ~,. V f'f : Location of Asbestos at the stte ~""~J" .....~^ ^. L.~ .~h _L" _ '..u::::." -~J:k-,-........ ~L-".: v.- Site Category: 0 ~hool 0 residence 0 college 0 industrial 0 commercial..a, other . : Start Date-1()- -I-I:t:\ Completion Date-'Iill-~.') ~ Hours on Site iUtrrl ~ Da.ys on Site'IYl-h' rol, '" Eme'!lency project notification requested: 0 N~r-- Di$CU$$ed with Date' ~ TYPE OF ASBESTOS MATERIAL ' , Type & Percent of Asbesto< 9:'7d11.l1"'7."qI'U" 0 Estimat~ Lab Quantity of asbestos in project ~~ :!of · 'l!J L' '< Linear A'Square 0 Cubic feet (I o Pipe, insulation Dtape. Dcemen~'tious(er. transite) ~f1oortile oroofing ofelt osprayon 1//lf/6;- . o valve packmg )( mastIC D sheet vmyl J( otherC" ,. 0 U ~' ~I ;, I tyla ~ WORK PRACTICES AND REMOVAL PROCEDURES ~ CIt:>O ~ . 1, , J( wet method 0 dry methods with air filtering 0 glovebag 0 containment 0 negative air ~eu t I ~o;, '- I 0 HEPA vacuum 0 vacuum truck with HEPA filter 0 other Ambient air monitOring to be performed: )(yes 0 no DISPOSAL PROCEDURES , o chute to dropbox 0 hand-load dropbox b<.wetted and double bagged ~other -f. . -v ~ '..' ""~ ~ ","""aste stored on site in secured container 0 waste secured off site at o waste removed daily ~ther , DISPOSAl SITE -""S~ort. Mountain. 0 Coffin Butte 0 other 'AB~~r~~o~e~~~CTO~T.EZ ')-111./-. - Lic~se~.- -FSi5',3~- n Mailing dress .lfEfrJn'L: '/~ . _~ ~ City . State ~ rc ZIP~Phon.. "7#1:L -"'7'7'7 -~~ Competent Person -. l~' ~, q'_ ~ '-.!.. _ Certificate No. CeUipager No. -'V1\-DU ~ PROPERTY.OWtiI'~. It:-&> -e.rJ /Dt~t!>" ~/ 5117, 5.!J1-~7-S Name ~f1 (I . '. "',"" p(\)..-.( L,; { t1.:I. I I Mail~~~dress . "~l"t -A-lo3 City ,.~,; _ Sa~0'l ZI~OI Phone..<\U,t,.- ~AA'-~3Y-- Name (Plea~e p" ~,f) J6nM.t2L1...aITJ.ani'Z1ltion /1-- T E ;z.. T.110_ Signature /' ~ -~ Phone .?"'II/Cf9f>b60'ir- Emai P . , a .ryj~_ DIl,tP ~-......-..... \ t:=- - --.= , i - , Asb:070109 Form Available on LRAPA website: www.lrapa.org Dee OS OS 01 17p '".. p.S C'P;':':':;:;.'; '-''-;',~;=.C.\'U_,~ .--.C' b."'h~X.;,\If:I',-". .:;;J"L1~' Certified Supervisor for Asbestos Abatement Projects .. ..... '...--, . '-'. - ,~~~H~l herSe,gg"R. s 11732 25MaylO ~,,<<.;,;~~tcl~~:;n:'.- - -~ii'-t,""'",j~_,"" 6Mar09 . 6Mar09 -L,:_~'C~: ';",~:s~ :,\1) l!~_:;"H':',':::; ,"." AI......~,....... w=r a-u-.lac. ~~DIO -...."'" ;,~,'- ~,'i,':-~p;'-,tii",,;;i"i;','l~ !.;,;; Qi;';,';;'~ !"; IC;U.,':ii l!l:'m;l \o'll:il:l!~~~-,; ~"':'1:,'l<::' .~". ". ~",Vg--; ~\:,~;.:;;~:;g~;;: 5~~ ",":,; ';;;,';;.' ?,?~Yr~'~:'- ,~",-, Dee 09 09 01 17p '-- p.10 ;'-'~I, l;;-, ,_:;:,.';;';;''.1('''' ':," f.:~;''';I<,~'.';.yf-,,: ',,<. I.J:.PL':' Certified Supervisor ~?~_ Asbestos _Ab.alem~nt PrOjects ,,~~y:.";tE.~ Sm~.~t1r'~"I"" ~11M~ic ..",~Han 10 IlDec08 IlDec08 -:e",",' '~l'~i_'~-:~~'~ w",~pl~. flHWR.. I"". J::::'&R~a~ ..."."., ~;;/:;;~:~;'~:~~~f~;.f~:::~~~~!~!~:'~;?::;~ ,,'" :~.:ot,~, I'd',!' ".-,.," 'j.,~ .'''.' "1~_;.' 1';.:.,\'1.,... I ".t~ -'.'~ Dee OS OS 01 18p p.11 (",:,,-':;" 3;,p";:;:~;':~.', ^.,...,:;'~.:':'j;~:..";;,, p":",,, ,I C',litfonl rl. .;iale:> ; '1:(;:7+, '-'~i:;~ilo ..~~1I.Q9 6/1/09 Safety Oire.ctlons u.c ;;.:.:,~.~);~l~~.:~.~J]~ .:~~~~..' \:;::;;;-;-i.:::",::.'.'<;':"';:'.: NOllCt; W1,'1'~;YJ"""'''OflH'I:;CI'''j.,l,SIlf:SK>S,'lf. 1,':U\;"l:)lltr~M':>:JI."'IIU'II',t:Jjtr.: ll'~II.1'~i ilEI'REP"-PFr,Af.6N" 'l"f-:JSHCwT-<'scrpc. ':J~ l't'J '''S1't;;;::iR YOU ~""I'I:JJ ll: I nn{.lN: =lS~ US!: Tl1ISC~."O '::::UMt}3~TIo.'.,- mJ.NIiUIlL lffFR~SHEA COURse IN QF.CU' Ie FEt<"W r.ftS C,>Rl! /' . ,<::n",^..l'OyL12:.SI:":1J." ".." (j?l'1!:""::-tnt(l 1I~: : ' r Dee OS OS 01 18p p.12 . . .,.,' .'~ . . ':.'''''~J\\'''''''''''.4''_''''.i,".,,,,,,,,,~,,,,,,,, t.<"'....""'.. ;,. - '. ~~~:,;;,~f,;;,~ NQTlCt; ..'IU, ,,,,_,~ ~~l ....'-lI'~. t-l(! ')II 'rJ ':'B~3 l'':i I!~. "".".'~: :.u Lfl';....!a... ~1I0h "nOJtcl. -.-0\. ~~J:'I r.~ rflP''1FC U ""n ;II.'C 'T. (;.r<l~' Tl"~ ';.\.'11_ \0 '. JOl.J ;NS~~Gr~"" '~JI.. r:M"'-~ll" 41."......" flS(VSf:T..qSCAAo)_'()'..'Ml.,!-!."-~t;.'If,^,'m.ru ~~,UKE\7~~~::.,:\L::~~:fN~W I~ ,. -':,"''''. >\~::+_._. nee OS OS 01:18p .-.>oF. _'0 p.l,3 ..:;~ :.!."."!':'1<r-';r,i _','~L ';~';_L'i;" Certified Worker tor ~sbesto3 Abatement Projects c.l-!<!rc:ps. Cat:<!P'lliL F}5648 ?MarlO "'~.':C_:;: ~"'_';!"\""'--.>. . ;...~:,-,'~", ;;..:':. 7Mar09 7Mar09 V,~.,".,!:\ 'to:.l>'~~~ ".\J ",(,_...:;",,"'7:~" . ~...........,... 'i;:r~r~' far.. farI,l....c:=.1MO -...."" "l,-,,,,.,-:~;'';':'-H '.r.".' '-'-~-'"'".'" '..is''''',!,"ik.;!''-: .~~,,,'''^'''' '-'''J ~.... "-:'~!.J.'" ,:".~.'",,~...,. .'"'VI< "~r'-,( ::t~::~~~~~;;'~'.~-,~: ~ :~'.:';..~':.' ?~~~~;;..~ "':" ! i I I , i I I I ! i i i , I , I I i I I Dee OS OS 01 lBp p.14 URF.GON UF."AR~'/fNT.:)F i:N./rRuNMEUT.t,LOUAI)n Certifiecl Worker_ for Asbes_tos Abatement Projects -.-.....:.....:..-_.'__ -. -".;'.~--- _ ._._ u. . .._ . , Naulfer B. Mor"les H. ':i'i"~'_T~"'-:; ---- - ~_..._,..>.~~'" iF 15019 18Mar09 i><"ll""~;ii(()'n~ T';;i;IiUr;n;.;~~-ri" 23Feb08 23Feb08 'r"m;;_'!..'~-s's..,;6l'f"lp";~t<O:--- A-bnt. '\'nIiai.. ~td "';~&~~rm, I.... ~.-!:,OAm~.'U40 ",,,,,,,,,,,, ~~~~.:~k,"f~~~~~~~~~~~t: b-{lhOllp:u1'11er~~!:"''':'-'Im''''''''';O-''''lIy,,".c,,'I)''Jl CniJ"'l>:" 3"".0>.,...,..,!~ a"<! \1--./1", TSCA T;lJ~ H Dee OS OS 01 1Sp p.15 . 1:.., :;.: ~.;'::~'~',~:~-.;:;::.~; ;":';:'" ,:;~'. ;,..", ~toL._Mediu:t :15H~ -'lO~/l0 ,M.1.I.I!1-. .?'lllJ9 .safety Din,diuns LLC '7~~ m~~~.~;~r~~f ';'-.'~~-'" . ~Ull(f. 1.><,<, ."'-'.....0 '_'''>>''''''.'''', "" ....-.-~~:l.'..' .~ JV:'l. ,0< t '.~".~,..., ~'"" ~'.;\It<; ~ -,: >>, "'~<: "r P~fP_'''~r, '.J ;u; rlU' "',sa..::: ,,,,~c^,.n l"hflf'1.~~'fr:I."lA ,.....';.Ullo:.; ;;" lIJV~'.. fLHJ:'_.;fTHL~r:~kO 1O"''''~' r\~r"'.l<Plll., ncrnr~>>~n eou~~~ l'l ;'".flfO(l' -': n;~~\\' -,H ~"n~ ~-mu_" ~llU~C ':'_.-"FO Dee OS OS 01 IS" ".16 , . . ,- ,""" . ",,--'''~'.'' " ~""'''''''''''''''.~''''''.^''''''''''' ,,"'..,. ~~~ir.:;>i(e.l.l~.., .'.!f8?~.. .}lle"JO ~i:;~'~;'n1::9 u~1 ~~ - '\., - - ~'~,~~0,,:ir .:.~~: ' NOflCt:. ":....." ':.J;'r';;.-",,,,_:,'~"". ~';"'.;~:' "~I.>; ,~n (~,:~I':","'':'I~~. '''''' ~C. .:<;~, ..._. "l "':'lJ<;.","u^lm-' ".>.i_ \")'H,''''''rJ,.,~(, )?.u"...;'.'(~!Cf' -:'J~"''',=:'-u.:\",,'::,,: :, 0' ',s~ ~.u< ,:.-:~ '.~ IIJ- .", ''''.' .oJ'. ~""'U^L ~EIR~""'" CC,,"U ,'J ,'1,1:"1 ~.-, Ri".'" nl" ~_M" NY'Nl.!.""'11,.~"I"'! ,;>5:Lw.c',~ Dee 09 09 01:19p p.17 ASN4 ~ ~ 00 01 /0D I ASBESTOS WASTE SHIPMENT REPORT FORIYI WA.STE GENERA TO~: rCOrHT1ClQr. Facility, or Opera lor) ^ : .'>belIOS removal "" n.meand address: l' ~ l'Y\IlA'(' \ A ,?-I .. . ill- . ~ t\> . s.", c..: OQ.. 10 I 'C UJ Ci'y/S,,,, C0""" p"son:~ ~ Co P ""-I I (J-o <1 ..J Op""or's name and address: ATEZ. INC. 23525 HIGHWAY 99 EAST HARRISBURG. ~ Srn:tl CitylStlle Wa", dosposal slIe:::=; ~.{ 'iY1.I"I\V\O'\ ~I', t-" 'pLEASE PRINT OR TYPE! If you have questions, COOlact your local DEQ Regional Office in Portland ar (<~:. ...,. 5364, Salem at (503) 378-8240 ex!. 272, Medford at (541) 776-6010 exl. 235. or Bend at (541) 388.6146 exl. 220. OR call (800) 452-4011 for the location of your local region.1 DEQ office. . P. '-i'l( 21- Z.p Pllnne 5C-/ 1- ~'il:V- ">(":2,-:o.,"{ Phone: (541\ qq<;_~.Q@ LANE 97446 Counf)' Z'p , 51rcCl CUy/Slate Counry Describe "besros materials: 'B ~ " ..l ~nf" . <...n~ ~11, >JlA- ~J Containers: Number: \ v Type: --i~' .r,,-, i;, To,,} quannry(eubic yard,): I~ Pllone: -5lJ 1- l.2ffl-~I~ lip o 17 i '! , OPERATOR'S CERTIFICATION: Illereby declue thai the contents 01 this consignment are fully and accu,,:c::.- described above by proper Shipping name and are classified, packaged, marked and labeled, and ar.. in all r"peel> '" proper condirion for lranspon by higllway according 10 all government regulations. All movement of this asb",o,. comaining ffialerial is recorded on this Waste Shipment Record Form. , Company: Date: ATEZ. INC. f (). i~.-(')'l Addre:ss. 99 E. HARRISBURG. OR 97446 /_,..r ~ . Company: Phone. ATE?. INr (541) 995-6008 Date:.Jo- r~-cR SignJrurc: , .-\g~nl: :\dd;,ss; _ Company: Phone: SlgTiJrurc: Olle: DISPOSAL: 'Cenil;earion of rec'ipr ofasbesto, marenal, covered by this manifest, except... nored in item 'I below.) . . \\,,,, Disposal Sire ~ ~ l'n~ .l~. ........ 'i<u--., ': Gillt-'--^' 1 A...J""--:'4 ~ /J. 1; '4 f."v... t~ '1,m"ndel~ew...lArD Rf'-ll.Al~'/1. ,Dale: /(J-/5 rJ9 . Slgnaru,,: -c... ()~.~ ""', /[<0 M ." ~ ,Phone: (541) 1:Jl~ _ ~,'.ll DISCREPANCY SPACE: (Add attachments as needed) .- '"-{"'ltO IYOI} ('1~) Dee OS OS 01:20p p. (8 ASN4 ~ ~ mIl 01 /iJ-o', ASBESTOS WASTE SHIPMENT REPORT FORM , ,.PLEASE PRINT OR TYPE! If you have question.!, contact your local DEQ Regional Office in Ponland ,,(5j,. ::;. 53~. Salem" (503) 378-8240 ext. 272, Medford al (541) 776-6010 e~t. 235, or Bend at (541) 388-6146 w. 226, Ol( call (800) 452-4011 for thelocanon of your local regional DEQ office, ., W.-\STE GENERATOR: (COntr.ilCLOr, Faciliry,orOpc:ralor) ^ , .\SbeslOS removal ~ ~.me and address: r IIYY\ 'fv\llAl' oC\:l\ A. ~ <<:::; . s.... C:OQ.. 10 I 'i: ~ru...t W City/Sllte CU""" p<rson:.j;ij"~ ~c_'-;'AC>..' \ rr-o .:e ~Ol . ...J O?Cr310r'S name and address: ATEZ. INC~ 23525 HIGHWAY 99 EAST HARRISBURG, ~. SrrUI Ciry/Stale Waste disposal si(e:~ 4l"Y!Qf " ,,!". ~,.. ~ ..\;." { U 11'\1" 9/.J,f-::Ll- Counry Zip Phone: 54/- ~'iOc- ~-::<,~~ Phone: ( 541 I QQ5-fiOOR Ll\NE Counry 97446 z" Phone:..=i!:I \ - 1..2.C-- ~,,~ SlreCI City/SlllC COllnry z;~ " Describe a,be"os malerials: ~ry.C,.... 0'" t\ \/ nl'" \,.L.nJ.L Slit~., '5.(/ {>, 0 Conlitners: Nwnber: \ TYPe: ~'-J. -""'y-~ 1:.1'''\ J Tot31 quantity {cl.lbic yard$}: ~ I' I , , OPERATOR'S CERTIFICATION: I hereby declare thai the conlenrs of this consignment arc fully and .ce"",,;-,- d~scrib('d above by proper shipping name and are classified, packaged. marked and labeled, and are- in all respects :c: prop<< condirion for transport by highway according to all government regulations. All movement oflb;s asbc"o,. ,om.ining material is recorded On this Waste Shipment Record Form. . TR.-\SSPORTER(S): T ra"'poner # I : l^cknowlcdgmenlor rec .-\gem: "1)8""""" UJ:riD'Il Company: Address. 23S2~ 99 E. HARll.ISIltJRG. OR q?'14~ PhoDe: Sir;n'Mc:~~~ ~~ Tr.osporm #2: (Acknowledgment ~ri'IS) . .-\g'"': 7' =" . Company: .\dd:r",: . Phope: SlgnaCUIc: \am~: _ Company: ATEZ. INC. DSle:J/')- j~""-l" A't'EZ. IN<" (541) 995-6008 . DSle: to- I~--cj=\ ,Datc: .. DISPOSAL: (C."ificarion of receipl of asbeslOS malerials covered by this manifesl, .,cept as nOled in ilem II below.) '. \\."cOisposaIS'lc~.l. rn".._.l~ .-,^ 'iS~"''1.(), 11L.1'Lfk..",,,.-,,../l v.,.Q-., 7:_-~-J4'U-"~ '1!meandTtlle:O~)~GI'J.1._u('-..I'^ ,Date: JO~/3_0 5? ,S'gn.rur<. ,r- ~Jt'"I....., ~ ~R. ~ ,,' ''f''>- _Phone: (541) ')~4 _~'~~ DISCREPANCY SPACE: (Add an.chmenlS as needed) .,( \ I~C(l l ~_,o I J (3~) Dee 09 09 01:20p p.19 ASN4 ~ N IiIm 0'11 0-0 I ASBESTOS WASTE SleW i,,fENT REPORT FORM . . ), ~. PL1WlIl "......,. OR TYPE! Ifyou.baw~ COIIIIIctyour local DEQ lU&kmal.0lIice ill PclrdaDd at (503) 229- S364, SUm at (S03) 378-8240 ex1. 272, Med1lJnI at (S41) 776-6010ex1. 23S, arBead at (S41)38U146 ex1. 226, OR caD (100) 452-40\1 tor !be 10Cl8ti0n ofyoar local, -b"".1 DEQ otIice. - ~~;:.e.~"~~~::e(~--:;t_.;~;:~), (\ n'vr {~ 0if-:A r.1 0 Pu.J..n~. .. _ .l ') c::., ~ IL\ S ~ -:?CfIY\C'\.."..tY r~' (~1 r;'. All 0 0 "'i 1 L.( I ) ~e..oQ... io i ...:. Gl_>l<t"...,,~ c-y . . , . _, Zip Ccmlact pasoD: ~ -,'" . , . :...'''' " " c, ,,; PlIoae:"5:U I - :2,_Q-li; - <;;;- "> 3 if 2. Cr -".""' SIl8ll1eIltld~: ATEZ. Inc. .Phoae: S4I.lJ9S.6IlOa --- ~99F. - 3. W_ diopoaa1l1i1e: VoIIev T _Us 219'72 C'.nfIln - Rl' . - . 4. Desaibe asbestos 1lI8leriaIs: I t. I, (\~, I .1-( 1 j. c. ._-;.. _ '" Number. I \ 6. TCJlBI4"",,,,:.,, (adlicyardsJ: \ 7. OPEIlATOR'S '-IIiICl.lnCA11ON: I bmby decIln lhat!be . ",,""._, ofdis .." olIo,. ... ""..an: fidIy 8Dd '.."". ,;) desc:ribedallove bypuper". :'''':''I;,_lIIIII are.L .:t.. ~. v' """"J,1IIIIIIr:Dd lIIId JaIlcIecI, lIIId... in an._. _ in '.proper., ;":'~'~'I: fOr 0.':....11: .,.,.~~tDaD..;,I" "'"......,.., ""!JI';"'.~" AD ..... ..., ",..of1l:lis.~.l~. ""',;..1 ..,c...;:.,,~,1!l. ---.:.... ....... w: ~,. ...~ .I.IIIIUiil1illl1l ,..'.., OJ ODUII:I. asce-,lt"I~ .,...., ~FCIDL 'Fr,:. '~1~.~. OR CiIJiSlalIo tJpn '17446 Coaaly Zip l'tIoae: S41.74So2l118 ConrRIIic OR. CityISIe \"'c\fl' ':....<..\ ~'i" -- m30 (\ Coaaly. I ,-, Zip 0 \.:k ,( A-. ( . - ""), I t...I.A[..--;O ou 1)pe:~,6 Name: ~~ _ _ [Ii;,,,.,,,,, _~ -:"rY-../h~ J- ....- ~ . C ""i~'''''..': ATBZ.IDI:::. DatIl:~n9 1RA..;1.J1ol .. :.l......".{S): 8. T.";'I.~ ., ~.... #1: (II ...... ":...;.... .... ..: ,,-...~.,..ofmiteriars) Apu1: .~R. K:;,g,.... ~23~ s.,~"."".. ".c:. - - ~ J ..- ..;----- 9. T.,,,,..\,< . ,"" #f2; ~ ..., .'"'"'''H''' .."ofJa:apt4 "...I";~ :.Js) ApaI: Address: si8aat=: .C""'Il";"'J~ . .,E~ Pboue: A 11lZ..1ne. S41-OO-UMll Dale: II \ ~:s-l en . ~",,;~,(;,.,~ . PIIoDe: Dare: ....o..!Ji.' ...JIAL: (C ..;,:I.:..".~.., of~,..c,;o,l'" ........" .............1.....,. COYa'ed,bythis "...".'.r.~'''_ cxapr:aaaotedinilem II be1cnr.) 10. W-Di8posaJSlte:VaIJl!!vT_ . ~_aaiITide:}l~ \-t\$:"'-tOI.ve.V \ Scale 0perIt0r s,,,,,,,,,,. ~ ('~ IYttH?"", . . u. ._~ 11. ,.I"'..........ANCYSPAQ: (Add8lL l,.,_"",,"-'odj Dale: . Phone: NO'I 2 5 2009 541.745-2011 (R..,;,odMll) Dee OS OS 01:15p p.1 CDC MANAGEMENT CORP. AN OREGON REAL ESTATE COMPANY Fax Cover Sheet Mail: 2295 Coburg Road, Ste 200, Eugene, Oregon, 97401 Phone: 541-338-8334 Fax: 541-338-8221 Email: skwright@cmc.net Office: 101 East Broadway, Suite 103 Eugene, OR 97401 I TO: I ATTENTION: FAX NUMBER: I Brenda I 1219109 541-689-6861 I FROM: I DATE: NUMBER OF 20 PAGES: I Sue I PHONE NUMBER: Comments: Dee OS OS 01:20p p.20 ASN4 ..-::s- ~ mm 0, 1Ot.)1 ASBESTOS WASTE Sn.u'tdENT REPORT FORM PLEASE~ ......,Jo OR TYPEllfyou have 'I'--~';_, ~your local DEQ Regiooa!Office inPort1alldat (503)229- 5364, Salem at (503) 378-8240 en. 272, Medfonl at (541) 776-6010 en. 235, or Bead st(541) 38UI46 en. 226, OR calI (800) 452-40 I I fur the location of your local regional DEQ office. ' WASTE"'....M\ATOR:(C,.."._,,,.Facility,or~)(\ Q \Q d L Asbestos nnnoval site II8me and address; ~ '" '0" ,., .r-I" t ~. r::ll-'\.c ., ~l\. "\ =.. ~ A ~ . ':;~'. W ''('r ~'~ cd! fr-Il:- . fju. r q 7 '0 I -o..-Oe. Y"\0U\(L\C""- ...,J- I i1y1S1all: - C<Jmny Zip. Q "~i rtO'"" . ?C~ (~""22' j Contact person: \t'11 L ~""O'\f.y.-y. (,''''t-''AJL..J~..,'-tu:::one:C--.Uf- .... ,,_ ^ --, ~( 2. Operator's name and address: A TEZ. 1nc. .ynone: 541-995-6008 23525 Hwv 99 E. ~. OR Linn ~446 - ~ C<Jmny Zip ]. Waste disposal site: Vallev Landfi11s PboDe: S41-745-2018 28972 r.nffin Butte Rd. . Corwlli. OR ~ 97330 - CityIS1all: Coamy Zip 4. Describe asbestos materials: ~ L.rl."" .L ( ... 5. c.~_:"....: Number: I Type: ..:&..LU' 4,') 6. TOla\ quanlity (cubic }'lII1Is): '--I. ''1 7. OPERATOR'S CERTIFICATION: I hereby dec:Iare dJat the canIenIs oflbis ClIIISi", "."_." are fidIy 8Dd _.__;/ dfSCribed above by proper shipping IllID1e aod are cla1siIied, par.Jrw<l, marked aod Iabel;d,'aod Ire in 811 respeds in proper ,.,"~;.:., furtnmsport~._':';"gto8llgovennneul~. ADm. ,,_.,.....of1l1islL1.....:.. '''''''';'';''8 lIIIIIeriaIis,..",:.201l1l1is Waste sr.:....... RecordForm. Name: ~~:7r~ - Si_~/';'fr-~-/~7& ~ . TRAN~Jt U"'~.I. ~~: 8. TI'lIIlSpOI1er #1: (AdwowlalgmanofnoceiptoflDlllerials) Agart; Raben R. KinvnD , Company: Address: 2]525 H_~~. O&.rL..J Phone: Sigllll1lR:~ /)z ~?- . ~ ~ ~ v -~__ 9. TI'lIIlSpOI1er#2:(~of.--,ptolIlllllaiaJs) "- . Agent: Address: <Ampany: A TEZ. roc. DaIe:_ln- Q)sr-01 A TIlZ. me. S41-99S-GOOIl .Dale:_IO -i))'{<.-(), -c:.;..i"......'= Signature: ........-. .4UUJ;ll1i;. Date: -.... uML: (Ccnific:alion .: "-';r' of ~ _~.o III8leriaIs _emf by this "..._,:...... Cll<:qlt as D01rxI ill ilem 11 below.) 10. Waste DisposaI Site: VaIJey I.aJtdfiIJs NameaodTitle;--ri~:-tl.,_ i-h' j ~1+OU.lf~-,I Scale Operator Signawn,: (, )-fhrl'~t-D IJ..).fI/\ '.) 11. DIliCREPANCYSPACE: (Add2L..:....~..;asDC<ded) ~ n...... ....... . Phone: on 2 Il WIll S41-745-2018 (Rmsed 6103)