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REPUBLIC N*AZARDOUS SPECIAL WASTE &BESTOS MANIFEST SERVICES 8.1-7 °49 d If waste is asbestos waste, complete Sections I, II, III and IV If waste is NOT asbestos waste, complete Sections I, II and III I C:FNFRATr1R IGwneratnr emmnlatac la-rl a. Generator's US EPA ID Numbbeerr�[ b. Manifest Document Number c. Page 1 of d .Generator's Name anq Location: �;;, .q e. Generator's Mailing Address: � cts3- SAV ��isz OPERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name and are classified, packaged, marked and labeled/placarded, and are in all respects in proper condition for transport according to applicable international and J, / f. Phone: ``-C.�� c.:....'$�G:�..Z?n.� C. -t g. Phone: 1 owner of the generating facility differs from the generator, provide: h. Owner's Name: i. Owner's Phone No.: j. Waste Profile # k. Exp. Date I. Waste Shipping Name and M. Containers n. Total o. Unit No. T e een accepted and to the best of my knowledge the fore20ing is true and accurate. Descr tion Quanti WWoI f. Erlqnature .Date GENERATOR'S•CERTIFICATION: I hereby certify that the above named materiat'is not a hazardous waste as defined by 40 CFR 261 or any applicable state law, has been property described, classified and packaged, and is in proper/condition for transportation according to applicable regulations; AND, If this 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 been treated in accordance with the requirements of 40 CFR 268 and is no longer a hazardous waste as defined by 40 CFR 261. p. Generator AutRprized Agent Name Print . Si nature _ r. Date II. TRAN TER Generator completes Ila -b and Transporter completes Ilc-e a. Transporter's Name and Address: --I - -1 it -715 ;jV c.ame riot `d+ -Si na e. Date nCCT11dATInrd /rener.tnr rn Iafe Ills -c nnrd rloctinatinn Rite nmmi Illd-nd a. Disposal Facility a Address: c. Responsible Agency Name and Address: C. US EPA Number d. Discrepancy Indication Space: e. Special Handling Instructions and Additional Information: OPERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name and are classified, packaged, marked and labeled/placarded, and are in all respects in proper condition for transport according to applicable international and national governmental regulations. . O erators Name and Title Print h. Signature I i. Date *Operator refers to the company which owns, leases, operates, controls, or supervises the facility being demolished or renovated, or the demolition or renovation operation or both b. I hereby certify that the above Named materia has een accepted and to the best of my knowledge the fore20ing is true and accurate. r e. Name of Authorized Agent Print f. Erlqnature .Date IV ASRFSTOS /Generator cmmnletesYVYand Ooerator complete IVa -i) a. Operator's Name and Address: c. Responsible Agency Name and Address: b. Phone: d. Phone: e. Special Handling Instructions and Additional Information: f. ❑ Friable ❑ Non -Friable ❑ Both % Friable % Non -Friable OPERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name and are classified, packaged, marked and labeled/placarded, and are in all respects in proper condition for transport according to applicable international and national governmental regulations. . O erators Name and Title Print h. Signature I i. Date *Operator refers to the company which owns, leases, operates, controls, or supervises the facility being demolished or renovated, or the demolition or renovation operation or both REV 12110 GENERATOR RETAIN RS-F11A