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REPUBLIC <br />SERVICES NON -HAZARDOUS SPECIAL WASTE 8 ASBESTOS MANIFEST <br />q {� "7 {� {" 0l t If waste is asbestos waste, complete Sections I, Ii, III and IV <br />.- 9 18 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 Numberb. <br />- <br />Manifest Document Number.- <br />c. Page 1 of <br />d. Generator's Name and Location: <br />f. Phone: <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 />f. Si nature <br />n. Total <br />Quantity <br />o. Unit <br />WWoI <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 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 />Generator Authorized Agent Name (Print) q. Signature <br />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. utb 1 INA 11UN generator compiete ma -c anu vesunauun one UUMVIUMb uiu-y) <br />a. Disposal Facility and Site Address: <br />b. <br />c. US EPA Number <br />d. Discrepancy Indication Space: <br />cg i _=lJt / ► s <br />I hereby certify that the above named material has been acce ted and to the best of my knowledge the foregoing is true and accurate. <br />f. Cl 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 oroper shipping name <br />,d are classified, packaged, marked and labeled/placarded, and are in all respects in proper condition for transport according to applicab;e international and <br />dional governmental regulations. <br />e. Name of Authorized Agent Print <br />f. Si nature <br />I q- Date <br />i. Date <br />IV. ASBESTOS (Generator completes IVa -f and Operator complete IVq-i) <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 />f. Cl 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 oroper shipping name <br />,d are classified, packaged, marked and labeled/placarded, and are in all respects in proper condition for transport according to applicab;e international and <br />dional governmental regulations. <br />q. Operator's Name and Title Print <br />h. Si nature <br />i. Date <br />'Operator refers to the company which owns, IPases, operates, controls, or supervises the facility being demolished or renovated, or the demolition or <br />renovation operation or both <br />REV 01114 GENERATOR RETAIN RS-F11A <br />