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A"A REPUBLIC NON -HAZARDOUS SPECIAL WASTE & ASBESTOS MANIFEST <br />. SERVICES <br />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 />f,F1UF0AT(1R (r;onoratnr rmmnlptpC la -r) <br />r. Generator's US EPA ID Number <br />b. Manifest Document Number <br />c. Page 1 of <br />J. Generator's Name -mnd Location: 2 <br />?t!(7. l.'�t✓ <br />Phone: _ . <br />e. Generator's Mailing Address: <br />,.t)r :ixti : i+i:4�i :2 C`:FJI':;. / <br />g. Phone: =•_i i.�� .. :�a ri't; 2C: i-04 <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 />'Operator refers to the company which owns, leases, operates, controls, or supervises <br />n. Total <br />Quantity <br />o. Unit <br />WtfVol <br />No. <br />Type <br />A-- I f Sinnnn— c. Date <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 />n„anr NJ— tPrinh I <br />I r. Date <br />II. TRANSPORTER( <br />a. Transportees Name and Address: <br />P," Cl'e Zar <br />1-4.- Ill, - nnrr rine+inn+inn (Zito i^mmnlotAC Illrf-n) <br />a. Disposal Facility and Site Address: <br />c. US EPA Number <br />d. Discrepancy Indication Space: <br />Fa;, mairj <br />e. Special Handling Instructions and Additional Information: <br />Friable ❑ Non -Friable ❑ Both % Friable % Non -Friable <br />S. Autw vR <br />and are classified, packaged, marked and labeled/placarded, and are in all respects in proper condition for transport according to applicable intemational and <br />national governmental regulations. <br />b. <br />Operator's Name and Title Print h. Signature i. Date <br />the facility being demolished or renovated, or the demolition or <br />'Operator refers to the company which owns, leases, operates, controls, or supervises <br />I hereby certify that the above named material has been accepted <br />and to the best of <br />my knowledge the foregoing is true and accurate. <br />A-- I f Sinnnn— c. Date <br />nrn+nc I\/m-f nnrl r)noratnr rmmnlptp IVn-il <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 classified, packaged, marked and labeled/placarded, and are in all respects in proper condition for transport according to applicable intemational and <br />national governmental regulations. <br />Operator's Name and Title Print h. Signature i. Date <br />the facility being demolished or renovated, or the demolition or <br />'Operator refers to the company which owns, leases, operates, controls, or supervises <br />WFv nt114 GENERATOR RETAIN RS-F11A <br />