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�R7i REPUBLIC NON -HAZARDOUS SPECIAL WASTE & ASBESTOS MANIFEST <br />SERVICES <br />L• a 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 comoletes 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 />d�;fti 11 tt s. u:d rAt WE:ry L;l !ltstcrli,3, ii.v <br />Sao Irld of wt C <br />f. Phone: Qt,_t_�F.y, rQ C 741eKf"?.11 <br />e. Generator's Mailing Address: <br />JUtLt tit! - cizL:UrU4 <br />18Z inwiustrw Dr <br />g Phone: R+.k-t<+^f r�A !fit` I71O-2WSW <br />If owner of the generating facility differs from the generator, provide: <br />h. Owners 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 />'Operator refers to the company which owns, leases, operates, controls, or supervises the facility being demolished or renovated, or the demolition or <br />rAnnvntinn nnAmtinn nr hoth <br />n. Total <br />Quantity <br />o. Unit <br />Wt/Vol <br />No. <br />Type <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 property 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 />Generator Authorized Agent Name (runt) I q z:)Ignarure I ' tea« i <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 nCCTIAlAT1r%KJ !(_o rntnr ommnlcta Ills -r, nnri r)aatinatinn tiitp rmmnletp.S illn-n) <br />a. Disposal Facility and Site Address: <br />A•.., .. <br />b. htitift Yi4, e A W36 2C(04W- <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 />and are classified, packaged, marked and labeled/placarded, and are in all respects in proper condition for transport according to applicable international and <br />national governmental regulations. <br />e. Name of Authorized Agent Print <br />f. Signature <br />a. Date <br />IV eSRFSTnR 1C;Pnaratnr rmmnletes IVa -t and Uoerator complete Ivo -I) <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 />and are classified, packaged, marked and labeled/placarded, and are in all respects in proper condition for transport according to applicable international and <br />national governmental regulations. <br />g. Operator's Name and Title(Print)___h. <br />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 />rAnnvntinn nnAmtinn nr hoth <br />REV 01114 GENERATOR RETAIN RS-F11A <br />