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QRW REPUBLIC lka SERVICES 3480'053.1 NON -HAZARDOUS SPECIAL WASTE & ASBESTOS MANIFEST If waste is asbestos waste, complete Sections I, II, III and IV If waste is NOT asbestos waste, complete Sections I, II and III GENERATOR (Generator completes la -r) a. Generator's US EPA ID Number b. Manifest Document Number c. Page 1 of d. Generator's Name and Location: e. Generator's Mailing Address: f. ❑ Friable ❑ Non -Friable ❑ Both % Friable % Non -Friable LIV d are classified, packaged, marked and labeled/placarded, and are in all respects in proper condition for transport according to applicable international and d Phone �'y At) g. Phone:f. If owner of the generating facility differs from the generator, provide: I hereby certify that the above named material has been accepted and to the best of my knowledcle the foreqoing is true and accurate. h. Owner's Name: i. Owner's Phone No.: j. Waste Profile # k. Exp. Date I. Waste Shipping Name and m. Containers n. Total o. Unit Type Description No. Quantity WtlVol F ' I T MAY ENVIRON',6 N TAL HEALTH CEPA T10 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 state law, has been properly described, classified and packaged, and is in proper condition for transportation according to applicable regulations; AND, if this 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 been treated in accordance with the requirements of 40 CFR 268 and is no longer a hazardous waste as defined by 40 CFR 261. Generator Authorized Agent Name (Print) q. Signature r. Date TKANSPUK ILK (ueneracor completE a Transporters Name and Address: *`i'l b. Phon@:'..i ;.: •;r. t` R. o.•i,� ,3 i<=<. MR04 c Driver Name (Print) I d. Signature l e. Date l 111 nFRTINATION (Generator rmmnlete Illa-c and Destination Site completes 111d -a) a. Disposal Facility and Site Address: c. US EPA Number d. Discrepancy Indication Space: d. Phone: e. Special Handling Instructions and Additional Information: f. ❑ Friable ❑ Non -Friable ❑ Both % Friable % Non -Friable nPERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name d are classified, packaged, marked and labeled/placarded, and are in all respects in proper condition for transport according to applicable international and ational governmental regulations. b. I hereby certify that the above named material has been accepted and to the best of my knowledcle the foreqoing is true and accurate. h. Signature i. Date e. Name of Authorized Agent Print f. Signature . Date IV_ ASBESTOS (Generator completes IVa -f and Operator complete IVq-i) a. Operator's Name and Address: c. Responsible Agency Name and Address: b. Phone: d. Phone: e. Special Handling Instructions and Additional Information: f. ❑ Friable ❑ Non -Friable ❑ Both % Friable % Non -Friable nPERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name d are classified, packaged, marked and labeled/placarded, and are in all respects in proper condition for transport according to applicable international and ational governmental regulations. g. Operator's Name and Title Print h. Signature i. Date _ '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 REV 01/14 GENERATOR RETABN RS+11A