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9W W REPUBLIC <br />44 SERVICES <br />3431 <br />NON -HAZARDOUS SPECIAL WASTE & ASBESTOS MANIFEST <br />If waste is asbestos waste, complete Sections I, II, III and IV <br />If waste is NOT asbestos waste, complete Sections I, II and III <br />GENERATOR (Generator comoletes la -r) <br />a. Generator's US EPA ID Number <br />b. Manifest Document Number <br />c. Page 1 of <br />d. Generator's Name and Location: <br />e. Generator's Mailing Address. <br />ti ., .,.,, ,."a.ia �G r:... s*v;• ,� .yirirt;f"rxj, __w <br />CSwf?! ry i':+5ti1i+�:G rS� �tY�'/ �.ti <�, L' ,' <br />a:C' i:4d3'*.Jt �;r <br />14Dr <br />f. Phone' t, " ::c'7 x' mf. ' <br />g. Phone: <br />If owner of the generating facility differs from the generator, provide: <br />h. Owner's Name: <br />i. Owner's Phone No.: <br />j. Waste Profile # <br />k. Exp. Date <br />I. Waste Shipping Name and <br />m. Containers <br />n. Total <br />o. Unit <br />No. <br />Type <br />Descri tion <br />Quantity <br />WWol <br />MAY 10 <br />2018 <br />ENVIRO <br />MEN I /ft <br />HEALTH D <br />FART <br />ENT <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 property 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 />Generator Authorized Agent Name (Print) q. Signature r. Date <br />TRANSPORTER (generator corn <br />a.Transporter's Name and Address: <br />b. Phone: <br />Ila -n ana I rans <br />iic-e <br />c. Driver Name (Print) I d. Signature I e. Date I <br />111_ DESTINATION (Generator complete Ilia -c and Destination Site completes 111d -a) <br />a. Disposal Facility and Site Address: <br />b. <br />c. US EPA Number <br />d. Discrepancy Indication Space: <br />1 hereby certify that the above named material has been accepted and to the best of my knowledge the foregoing is true and accurate. <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 />d are classified, packaged, marked and labeled/placarded, and are in all respects in proper condition for transport according to applicable international and <br />etional governmental regulations. <br />e. Name of Authorized Agent Print <br />f. Signature <br />I q. Date <br />IV. ASBESTOS (Generator completes IVa -f and Operator complete IVg-i) <br />a. Operator's Name and Address: <br />b. Phone: <br />c. Responsible Agency Name and Address: <br />d. Phone: <br />e. Special Handling Instructions and Additional Information: <br />f. ❑ Friable ❑ Non -Friable ❑ 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 />d are classified, packaged, marked and labeled/placarded, and are in all respects in proper condition for transport according to applicable international and <br />etional governmental regulations. <br />g. Operator's Name and Title Print <br />h. Signature <br />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 />renovation operation or both <br />REV 01/14 GENERATOR RETAIN RS-F11A <br />