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REPUBLIC NON-HAZARDOUS SPECIAL WASTE & ASBESTOS MANIFEST <br /> SERVICES <br /> 1916962 If waste is asbestos waste,complete Sections I,II,III and IV <br /> If waste is NOT asbestos waste,complete Sections I,[land III <br /> I. GENERATOR (Generator completes la-r) <br /> a.Generator's US EPA ID Number b. Manifest Document Number T <br /> Page 1 of <br /> d.Generator's Name and Location: e. Generator's Mailing Address: <br /> f. Phone: g. Phone: <br /> If owner of the generating facility differs from the generator,provide: <br /> h.Owner's Name: i.Owner's Phone No.: <br /> j.Waste Profile# k.Exp.Date I.Waste Shipping Name and m.Containers n.Total o.Unit <br /> Description No. Type Quantity WVVo1 <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 /> p. Generator Authorized Agent Name(Print) I q. Signature r.Date <br /> II. TRANSPORTER Generator completes Ila-b and Transporter completes Ilc-e <br /> a.Transporter's Name and Address: <br /> b. Phone: <br /> c.Driver Name Print d. Signature e.Date <br /> III. DESTINATION (Generator complete Illa-c and Destination Site completes Illd-g) <br /> a. Disposal Facility and Site Address: c.US EPA Number d. Discrepancy Indication Space: <br /> b. <br /> I hereby certify that the above named material has been acce ted and to the best of my knowledge the foregoing is true and accurate. <br /> e.Name of Authorized Agent Print f. Si nature q. Date <br /> IV. ASBESTOS (Generator completes IVa-f and Operator complete IVg-i) <br /> a.Operator's Name and Address: c.Responsible Agency Name and Address: <br /> b. Phone: 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 /> g.Operator's Name and Title Print h. Signature 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 operation or both 71 <br /> REV 01114 DESTINATION RETURN RS-F11A <br /> A <br />