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qAA REPUBLIC <br />446 <br />SERVICES <br />NON -HAZARDOUS SPECIAL WASTE & ASBESTOS MANIFEST <br />•-, rr }, <br />j ' If waste is asbestos waste, complete Sections I, II, III and IV <br />`t If waste is NOT asbestos waste, complete Sectio^ ; 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 />e. Generator's Mailing Address: <br />IXJFf:`.. t:�9:;;.i,:� ,::rt1�;'f' _ � r,^•.�i: ��..., <br />1tq'L�``Q IrKtAtistl Dr. <br />alt.,,.': 'r� .� : nn =* �f'�'_-•�- <br />16i 1rAAL-W Or <br />�� <br />f. Phc 1e: <br />g. Phone: <br />If owner of the generating facility differs from the generator, provide: <br />i..tional governmental regulations. <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 />Description <br />Quantity <br />WI/Vol <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 b 40 CFR 261. <br />D. Generator Authorized Aoent Name (Print) q. Signature <br />r. Date <br />II. TRANSPORTER Generator completes Ila -b and Transporter completes 11c -e) <br />a Transporter's Name and Address: e� <br />b. Phone: <br />c. Driver Name Print d. Signature e. Date <br />III nERTINOTif)N MPnpratnr rmmnlete Ills -r and Destination Site comDletes 111d -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 knowledge the regoinq is true and accurate. <br />b. Phone: <br />d. Phone: <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 />I ULK <br />b. Phone: <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 />a•id are classified, packaged, marked and labeled/placarded, and are in all respects in proper condition for transport according to applicable international and <br />i..tional governmental regulations. <br />q. Operator's Name and Title(Print) h. Si nature i. Date <br />'Operator refers to the company which owns, leases, operates, controls, or supervises thi )ing demolished or renovated, or the demolition or <br />renovation operation or both <br />REV 01/14 GENERATOR RETAIN A / RS-F11A <br />