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RW REPUBLICc NON - HAZARDOUS SPECIAL WASTE & ASBESTOS MANIFEST SERVICES 1, I If waste is asbestos waste , complete Sections I , II , III and IV t S ) CM 2 . C14 : 1 If waste is NOT asbestos waste , complete Sections I , II and III i I I . GENERATOR (Generator completes la- r) i a . Generator's US EPA ID Number b . Manifest Document Nnmoer c. Page 1 of 0 b d . Generator's Name and Location : e . Generator's Mailing Address : 14 f. Phone : f l� �I 4 tj Er`/ ` I 02�42 e2 g . Phone : If 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 Description No . Type Quantity Wt/Vol 1 .1 . 43 4 RECEIVED JAN 0 3 2020 GENERATOR'S CERTIFICATION : I hereby certify that the above na NMENTAv+q oAi"te as defined by 40 CFR 261 or any applicable state law, has been properly described , classified and packaged , and is in PffRIMR09iQrpfprl arortation according to applicable regulations ; AND , if this waste is a treatment residue of a previously restricted hazardous waste subject to the La�ffnd 1s``p'd��all 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 Authorized Agent Name ( Print) q . Signature r. Date 11 . TRANSPORTER Generator completes Ila- b and Transporter completes Ilc-e a . Transporter's Name and Address : , 5 b . Phone : + 1=1 111150 Fc. Driver Name Print d . Signature I e . Date III . DESTINATION ( Generator complete llla- c and Destination Site completes llld -g ) a . Disposal Facility and Site Address : c. US EPA Number d . Discrepancy Indication Space : b . 1 hereby certify that theabove named material has been accepted and to the best of my knowledge the foreqoinq is true and accurate . e. Name of Authorized Agent Print f. Signature I a . Date IV . ASBESTOS (Generator completes IVa-f and Operator complete IVg - i ) a . Operator's Name and Address : c . Responsible Agency Name and Address : i b . Phone : d . Phone : e . Special Handling Instructions and Additional Information : 11 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 j national governmental regulations . g . Operator's Name and Title Print h . Signature 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 01 /14 TRANSPORTER RETAIN RS-F11A