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�EPURLib NON-HAZARDOVjSP'ECIAL WASTE & ASBESTOS MANIFEST <br /> .SERVICES ' <br /> "a• 86'9993 If waste Is asbestos waste,complete Sections to II,Ill and IV <br /> If wasta is NOT asbestos waste,complete Sections t,11 and III <br /> I. GENERATOR ((3enerator completes Ea-r) <br /> Fd, <br /> Gen) u's U5 EPf 11)Numbor b.Manifest ocu r C.Page 1 of <br /> goneraier's Namo fa �LoGatton: e.Generator's Mailing Address: <br /> f.Phonne:�ii2•�'t�h �� ! I�J7�j�' g.Phone: J�-i. ancIsGoC's 9���° <br /> If owner of the generating facility differs from the denerator,provide: <br /> h.Ownat's Name' 1.Owner's Phone No.: i <br /> 1.Waste Profile# k.Exp.nate I.Waste Shipping Narpe andn.„ z.Cofttal ers n.Total o,Unit <br /> Descri lion No. Type Quantity WINO! <br /> � /CO <br /> CM 15- <br /> GENFRATQ 'S.CERTIFJCATION: I hereby certify that the above named nlatgriat Is not a hazardous wasle as dofinad byA0 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 roquitenienls of 40 CFR 26tt nd is no longer a hazardous Wast,as defined%v40 OFIR 251, <br /> p.GuneraW Authorized A eni Name Print I natufe. r.Data <br /> II. r TRANSi?ORTER (Generator compfntes Ila-b and Trarts orter completes Ilc-e) <br /> I a.Transporter's Name and Address; t �i, t P �J� �a'i;;T i G ( SevvfCC <br /> 1 <br /> IS 0�. ��'iC' f�0 Y1 0-y- <br /> 18 <br /> b.Phone: 00 �t-ice b/�I s t�C't , c� j+t�Z3 &t74# <br /> c.Driver N ma Print Si natu J e.Date <br /> III. DESTINATION (Generator coinplpte lila-c and Destination Site completes 111d-g) <br /> a.Dlsp ai Facility and Site Address:n c.US EPR Numbor il,Discrepancy Indication Space: y <br /> i`1 r/�v5nr �p <br /> b, All lC C ( � �— <br /> I hereby cert[N that the above named nmlerfal has been bast of my 1< owfeil a tho foregoing is true a "Wa e. <br /> e.Name of Authorized Agent Printt'n titre Dale <br /> IV. ASBESTOS (Generator completes IVa-f and Opera'Corcompiete•iV -i) <br /> a.Operators Name and Address: o.Responsible Agency Name and Address: <br /> b.Phone: d.Thane; <br /> e.Special Handling Instructions and Additional Information: <br /> Friable U Non-Frlabte U troth %Friabie %Nan-friable _ <br /> OPERATOR'S CERTIFICATION:I hereby declare that the contents of this conlaignment are fully and accuraWy described above by the proper shipping name <br /> and are classllied,packaged,marked and labeled(placarded,and are In all respects in proper condition for transport according to applicable International and <br /> nattonpl overnmental regulations. <br /> r <br /> ;;;� <br /> Operator's Name and Title Print h.Signature t,Date <br /> 'Operator refers to the company wh1oh owns,leases,operates,controls,or supervises the facility being demolished or renovaled,or the demolition or <br /> renovation operation or both <br /> REV 12JI0 RETURN TO GENERATOR RS•FIW <br /> :i <br />