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9W7i REPUBLIC NON -HAZARDOUS SPECIAL WASTE & ASBESTOS MANIFEST <br />SERVICES <br />S ✓+ rtl t+ If waste is asbestos waste, complete Sections I, II, III and IV <br />If waste is NOT asbestos waste, complete Sections I, 11 and III <br />GENERATOR (Generator completes la -r) <br />3. Generator's US EPA ID Number <br />b. Manifest Document Number <br />C. Page 1 of <br />J. Generator's Name -nd Location: <br />Phone: ... - _.. �-#-•_.... iYf}g. <br />e. Generator's Mailing Address: <br />Phone:JF�ti.:i.'f,,, at�'~' '..�..-3:.:1•:::C:i <br />f owner of the generating facility differs from the generator, provide: <br />i. Owner's Name: <br />i. Owner's Phone No.: <br />Waste Profile # <br />k. Exp. Date <br />I. Waste Shipping Name and <br />Description <br />m. Containers <br />in. Total <br />Quantity <br />o. Unit <br />Wt/Vol <br />No. I <br />—Type <br />kd <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. I certify and warrant that the waste has <br />been treated in accordance with the requirements of 40 CFR 268 and is no longer a hazardous waste as defined by 40 CFR 261. <br />p. Generator Authorized Agent Name (Print) <br />. Signature r. Date <br />II. TRANSPORTER Generator completes Ila -b and I rans orter completes Ilc-e <br />a. Transporter's Name and Address: <br />b. Phone: <br />c Driver Name (Print) d Signature I e. Date I <br />nwt inr.i fr''-onorotnr rmmnlota Ills -r nnri rlpctinatinn Sita romcletes 111d -o) <br />a. Disposal Facility and Site Address: c. US EPA Number <br />d. Discrepancy Indication Space: <br />mai J :.fit • y <br />d. Phone: <br />e. Special Handling Instructions and Additional Information: <br />❑ Friable ❑ Non -Friable ❑ Both % Friable % Non -Friable <br />)PERATOR'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 classed, packaged, marked and labeled/placarded, and are in all respects in proper condition for transport according to applicable international and <br />b. _ <br />I hereby certify that the above named material has been accepted and to the best of <br />my knowledge the foregoing is true and accurate. <br />.a...... +;i --tion nr hnth <br />..r A..H .I A A ,on« for nti I f Rinnah irp a. Date <br />mm�latac [\/n -f nnri rinprptnr rr)mnlptp IVn-i) <br />a. Operator's Name and Address: <br />c. Responsible Agency Name and Address: <br />b. Phone: <br />d. Phone: <br />e. Special Handling Instructions and Additional Information: <br />❑ Friable ❑ Non -Friable ❑ Both % Friable % Non -Friable <br />)PERATOR'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 classed, packaged, marked and labeled/placarded, and are in all respects in proper condition for transport according to applicable international and <br />national govemmental regulations. <br />g. Operator's Name and Title Print h. Signature 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 />.a...... +;i --tion nr hnth <br />:zFv mi1a GENERATOR RETAIN RS-F11A <br />