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C <br />�K7i REPUBLIC NON -HAZARDOUS SPECIAL WASTE & ASBESTOS MANIFEST <br />�V SERVICES <br />V 4 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 completes la -r) <br />a. Generator's US EPA ID Number <br />Manifest Document Number <br />T <br />c. Page 1 of <br />d. Generator's Name and Location: <br />f. Phcne: <br />e. Generator's Mailing Address: <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 />Description <br />m. Containers <br />n. Total <br />Quantity <br />o. Unit <br />WtfVol <br />No. <br />Type <br />Ilk t <br />Ei` <br />!VI <br />r <br />n C <br />IQ <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 />r na—f— At thnri7aH Anant Nama (Print) I n Signature r. Date <br />TRANSPORTER Generator completes Ila -b and Transporter completes lic-e <br />a. Transporter's Name and Address: <br />b. Phone: <br />c. Driver Name Print d. Signature e. Date <br />III DESTINATION (Generator complete Ilia -c and Destination 51te completes nla-g) <br />a. Disposal Facility and Site Address: <br />b. <br />c. US EPA Number <br />d. Discrepancy Indication Space: <br />I 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 />1 are classified, packaged, marked and labeled/placarded, and are in all respects in proper condition for transport according to applicable international and <br />,onal governmental regulations. <br />e. Name of Authorized Agent Print <br />f. Si nature <br />1 q- Date <br />ni necceTrIQ lrlcnarotnr rnnnnlatac 1\/a_f anri t)n?rntnr Cmmnlprp IVa-li <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 />1 are classified, packaged, marked and labeled/placarded, and are in all respects in proper condition for transport according to applicable international and <br />,onal governmental regulations. <br />g. Operator's Name and Title Print 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 -F1 1A <br />