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REPUBLIC <br />SERVICES <br />MON-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 completes 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 />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 />^OERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name <br />n. Total <br />Quantity <br />o. Unit <br />WWol <br />No. 7 <br />Type <br />g. Operator's Name and Title Print <br />h. Signature <br />I 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 />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 />,enerator Authorized Agent Name Print . Signature <br />r. Date <br />TRANSPORTER Generator completes Ila -b and Transporter completes Ilc-e) <br />a,Transporter's Name and Address: <br />b. Phone: <br />c. Driver Name Print d. Signature e. Date <br />111 nESTINATION fGPnerntnr (-mmnlete lila-c and Destination Site completes llld-a) <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 knowled a the fore oin is true and accurate. <br />f s':'►'t�j <br />! <br />e. Name of Authorized Agent Print <br />f. Signature . Date <br />IV_ ASBESTOS (Generator comDletes IVa -f and Operator complete IVq-i) <br />a. Operator's Name and Address: <br />c. Responsible Agency Name and Address: <br />1t? X 36 <br />f s':'►'t�j <br />! <br />b. Phone: <br />d. Phone: _ <br />_ <br />e. Special Handling Instructions and Additional Information: <br />3.4k Prv\. <br />f. ❑ Friable ❑ Non -Friable ❑ Both % Friable % Non -Friable <br />^OERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name <br />I 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. -i] <br />g. Operator's Name and Title Print <br />h. Signature <br />I 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 0104 GENERATOR R=-TAI+l RS -F1 1A <br />