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�$ REPUBLIC NON-HAZARDOUS SPECIAL WASTE & ASBESTOS MANIFEST <br /> gv�V SERVICES <br /> dr' If waste Is asbestos waste,complete Sections I,11,III and IV <br /> If waste Is NOT asbestos waste,complete Sections I,II and III <br /> h GENERATOR (Generator completes la•r) <br /> a.Generator's US EPA ID Number b,Manifest Document Number C.Page 1 of <br /> —_—. <br /> d.Generator's Name and LoceOon; e:Generator' MoiMoiling Atltlresg: - -- --- <br /> If owner or the generating facility diff rra from the gonarator,provide: —� <br /> h.Owner's Name: 1.Owner's Phone No.: <br /> j.Waste Profile 8 k.Exp,Dale I.Waste Shipping Name and an.Containers n,Tale) o.Unit <br /> Description No. Type Quantity wwol <br /> — I <br /> GENERATOR'S CERTIFICATION: i hereFC0rlItYV l the above named material Is not a hazardous waste as dented by 40 CFR 261 or any applicable <br /> slate law,has been properly described,classified and packaged,and is In proper condltion for transportation according to applicable regulations;AND,It this <br /> waste is a treatment residue of a.previously,restricted hazardous waste subject to the Land Disposal fjaslriclkms.I certify and warrant that the waste has <br /> been treated in aocordange with(he,requirements.of 40 APR 268 and Is no longer a hazardous waste as defined.by 40.CFR 261. <br /> ).Generator Authorized Agent Name(Pdnita.SMrlolure .rDole <br /> - -"- - <br /> IL TRANSPORTER (Generalor cornnletes Ila-b and Transporter completes <br /> a.Transporter'$Name and Address: <br /> , <br /> b.Phone: <br /> c.Driver Name(Print) d.Signature e.Date <br /> Ill. DESTINATION (Generator complete Illa-c and Destination Site completes Illd-g) <br /> a,Disposal Fac11h1 and Site Add=JJM1n <br /> EPA Number d.Discrepancy Indloalion Space: <br /> b. <br /> thumb corlif Ihel lira almvn nato His beat ofmy knowlnd n the Inregnbm Is Imo and aecucdu. <br /> e�lame of Authorized A — <br /> -._ jnatnnt ue. ,Dale <br /> IV: ASBESTOS (Generator completes IVa-f and Operator complete IVs-i) <br /> a.Operators Name and Address: 'c.Responsible Agency Name and Address: <br /> b.Phone: d.Phone: <br /> e,Special Handling Inalructions and Adehlonal rnlnrmauon: - -- <br /> .r LI Friable O NonFrable ❑ Both /,Friable „Non•Frioble " <br /> OPERATOR'S CERTIFICATION:I hereby declare that the contents of this consignniant ere fully and accurately described above by IAa propersRpiping nama <br /> and are classified,packaged,marked and labeled/placarded,and are In all respects In proper condlllon for transport according to applicable international and <br /> _national nevommenlnl It Nations. <br /> a.O orators Name and Title Print) I h,Signature I Date <br /> Operator refers ration of beth to the company Ich owns.leases,operalos,contra s,or aupervlses the <br /> renovation oracl lly being demolished or renovated,or the demciorldon <br /> REV 01/14 f28.F1fA <br />