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ofs REPUBLIC NO%AZARDOUS SPECIAL WASTE RSBESTOS MANIFEST <br />Ij►Zi SERVICES <br />869334 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 />I. GENERATOR (Generator completes la -r) <br />a. Generator's US EPA ID�{f umber <br />C <br />b. Manifest Document Number <br />c. Page 1 of <br />d. General r s Marnefand Location: - <br />c;�,.tIDELG. �l� SioGieio.✓ <<e <br />f. Phone: <br />e. Generator's Mailing Address: <br />Q� moo/ a��v6L�✓!/r����T� <br />hon`%/�� <br />If owner of the generating facility differs from the generator, provide: <br />h. Owner's Name: <br />i. Owners Phone No.: <br />j. Waste Profile # <br />k. Exp. Date <br />I. Waste Shipping Name and <br />DescriptionType <br />m. Containers <br />L Si nature <br />n. Total <br />Quantity <br />o. Unit <br />Wt/Vol <br />No.--F— <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 <br />. Signature I r. Date <br />a. Transporters Name and Address: _��+' .�J"/ /O�/7� �� �,✓G' <br />P© /1 OX 3:5 % L 0JJ/ cA, -;i4/ <br />III. DESTINATION (Generator complete Illa-c and Destination Site completes Illd-q) <br />a. Disposal Facility and Site Address: c. US EPA Number <br />9 9y s. '0' <br />b. <br />d. Discrepancy Indication Space:��' `� / <br />Z <br />I h e at ove named material ha been a ted and to the b "'m <br />knowled a the foreoin is true and accprate <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 />. O erelI Name and Title Print <br />h. Signature <br />b-flffi <br />me ofAuthorized A and Print <br />L Si nature <br />['g.Date <br />IV. ASBESTOS (Generator con{pletes IVa -f and Operator com gWq <br />a. Operators 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 />. O erelI Name and Title Print <br />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 o oration or both <br />REV 17/10 RETURN TO OPERATOR RS-F11A <br />