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REPUBLIC NON -HAZARDOUS SPECIAL WASTE & ASBESTOS MANIFEST SERVICES 5 ry If waste is asbestos waste, complete Sections I, II, III and IV ; , 9 If waste is NOT asbestos waste, complete Sections I, 11 and III r.FNFROTr)R (C'Pnprator completes la -r) i. Generator's US EPA ID Number b. Manifest Document Number c. Page 1 of J. Generator's Name nd Location: Phone: s _. e. Generator's Mailing Address: g. Phone: f owner of the generating facility differs from the generator, provide: i. Owner's Name: i. Owner's Phone No.: Waste Profile # k. Exp. Date I. Waste Shipping Name and Description m. Containers 'Operator refers to the company which owns, leases, operates, controls, or supervises the facility being demolished or renovated, or the demolition or n. Total Quantity o. Unit Wt[Vol No. I Type I f. Si nature Date 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. p. Generator Authorized Agent Name (Print) . Signature r. Date r.rc�T��wr�nu I!''_...,.... -,+..r --- nleto III—r nnrl rloctinntinn SIfm r.mmnlP-tP.S lllri-n) a. Disposal Facility and Site Address: I c. US EPA Number d. Discrepancy Indication Space: d. Phone: e. Special Handling Instructions and Additional Information: ❑ Friable ❑ Non -Friable ❑ Both % Friable % Non -Friable CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name iPERATOR'S and are classified, packaged, marked and labeled/placarded, and are in all respects in proper condition for transport according to applicable international and national governmental regulations. b. 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 I hereby certify that the above named material has been accepted and to the best of my knowledge the foreqoing is true and accurate. e. Name of Authorized Agent (Print) I f. Si nature Date c.nr�.rne ic....,, +^, - minfmc Wn_f nn.A r)narntnr rmmnletP IVn-il -----. -- x--- -- -- -- - a. Operator's Name and Address: c. Responsible Agency Name and Address: b. Phone: d. Phone: e. Special Handling Instructions and Additional Information: ❑ Friable ❑ Non -Friable ❑ Both % Friable % Non -Friable CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name iPERATOR'S and are classified, packaged, marked and labeled/placarded, and are in all respects in proper condition for transport according to applicable international and national 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 .,,,.+;,,., --ti— nr hnth _ :?FV n1/14 GENERATOR RETAIN RS-F11A