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<br /> i REPUBLIC NONHAZARDOUS SPECIAL. WASTE & ASBESTOS MANIFEST ,*4' 't�� � y
<br /> itS► SERVICES
<br /> w 7 If waste Is asbestos 3v;r3tc,Complete Sections t,It,.III and IV
<br /> If wasto is NOT asbestos%vaste,cornpfeteSectUis I, II and III
<br /> ft. GENERATOR (Generator completes.la-r) — _— _- _--- -
<br /> a.Generator's L-1S EPA f0 Number t,.I1ianifesl gocumcnt Nu:rilaer i c.Page 1 of
<br /> d.Generator's Name and Location —�- e.Generator's malllnAddress:
<br /> f'AQ 1f:OAS 0 i t f=f::IM,
<br /> 1-36? /d, 4ybyr2 f1_10 BOX 1040
<br /> i jtC!le%�+fj e'r?`-P61'a4 5,f;.N 0A0 11 'I3
<br /> f. Phone: _ 1d� ' g.Phone: -
<br /> If owner of iho generating facility drlfors front Ilse generator,provide:
<br /> It Osv_her's Name: _ i.Ownor's Phone'No.: �-
<br /> 1 ].1Arasfe Profile tf - k.Exp,dale I Wasto SbIpping Name and ni Containers n:Feta! o, Unit
<br /> Descrl lion No Tyj,e� Quandt wuvol
<br /> i
<br /> i
<br /> 1a$t t 1��KF�tIC t:klla 4i . #iEl ;sE°£sz�a4_ i rwr ,/ ', Y
<br /> GFNERATOR'S CERTH-Ic 'rfON; I hereby cerlify Ihal tfte alcove named malorlal is nul a hazardous tvasle as defined by 40 OFR 261 or any applicable
<br /> state Iaw,lies baen propfly cfuserlbed,classified and packaged,and Is In prolx,i condition for lransporiallon according to appl?cable fegulal{ons;AND,If this
<br /> Jiaste is a ImHlnienk`rasidue of a pteviausty restricted bazarda�s,tivaste subjer.t io Ilio Land DI9poral Restrictions.I Certify and Warrant that the waste tial
<br /> been III,are�ordnnce trifh the roclUfrements of 40 OFf2 26gond is no i ngnr n Imzardous wasto a.,defined b 40 CFR 26-1.
<br /> ( I{ �./ Jr. lli.�Il, !�+`-�1r /f �r` �✓ _w.�_d. _ 'Da
<br /> Z-1^
<br /> --.� r. Data --t
<br /> �a C, rooster Authareed kjent Name Print_ I q. nature —__
<br /> If. TRANSPORTER (Geru,rator completes f{a-b and Trans orter coi�etes
<br /> a.Transporters Narrte and A,ddreO T I
<br /> 1'1i{1.IPVVE';T11VWEs'II1IN . �j�?�
<br /> 1HO? hlCt.I'f�N 1'sfA r
<br /> b.Phone:
<br /> 1 R ll iBT t4,0
<br /> d. TlLialu—o -_ �. o. saluc. Ddvcr NamePrint
<br /> - .__-- --
<br /> 111, DESTINATION (Generator complete Vlore and Destination Site, completes llld q),
<br /> a.Dlspcis l.F Cl i� r I e - c.US Nurrkbv J.Dlscrepan�y Iridiii,tion Blasco:
<br /> Wfj', { VIN�1,11
<br /> A
<br /> il �JI�CJiff/
<br /> it:Rf/'a t
<br /> _b. !
<br /> Ihereby certifrtiiat the above nun,L�i!itiataria!has beers cc gated apti Inc th ly s1 of my know ed'a he fore•In Is true bn� urala.' /
<br /> -�-.-.r.- _ - - Tn T '
<br /> a,Name of._Auih-__ oriz@d Age�nt�Prirrw4_—___--_.' f.Sl rta urc !� •, � ;g�l�rt+i_ - �` ;
<br /> IV. ASBESTOS (Generator completes'IVa-f atui Operator complete ll
<br /> a.Operator's Nanta and Address T - c.Responsible Agpmcy Nano,and
<br /> i - 148CEIVED
<br /> b.Phone d. Phone;
<br /> e.Special Handling Instructions and Additional Information. - Ajry
<br /> I R --
<br /> _f.0 1 d8ble ❑ Non-Friable Cl both — — %f=riable %Non-Friable
<br /> OPERA-102'5 CERTIFICATION:I haroby declare that the contents o1 thrs
<br /> consignment aro fully:anci accurately d hrg narr,e
<br /> and are classified,packayad,narked and labeled/placarded,and.are In all respects In proper condition for transpork sat and
<br /> national governmental reg�ulaiiozrs --
<br /> I mac:r3_Liaraior'e Narno and TllloPnn� It Signature I. pd,tu ,-
<br /> i 'Operator r;afors to Iho_company wbirl,cxinss,loRf 0s,operates,controls;or suservrse9 tlne.iacilfly-being doniolishocl orrenovatud,or Il,o domlalill or)rrr
<br /> ! reroyallon opera or hath - -
<br /> i - - 17 of 17
<br /> REV 12110 JtF't'1912N "ll� OLN1 J<, I'01? rt rt1A
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