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REPUBLIC NON-HAZARDOUS SPECIAL WASTE & ASBESTOS MANIFEST SERVICES i If waste is asbestos waste,complete Sections I,II,111 and IV If waste is NOT asbestos waste,complete Sections I,11 and III I. GENERATOR (Generator completes la-r) a.Generator's US EPA ID Number b.Manifest Document Number c.Page 1 of d.Generator's Name and Location: e.Generator's Mailing Address: f.Phone: g.Phone: If owner of the generating facility differs from the generator,provide: h.Owner's Name: I i.Owner's Phone No.: j.Waste Profile k.Exp.Date I.Waste Shipping Name and m.Containers n.Total o.Unit Description No. Tye Quantity WtfVol 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 state law,has been properly described, classified and packaged,and is in proper condition for transportation according to applicable regulations;AND,if this 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 been treated in accordance with the requirements of 40 CFR 268 and is no longer a hazardous waste as defined by 40 CFR 261. 1 T___ p.Generator Authorized Agent Name(Print) I q. Signature r.Date 11. TRANSPORTER Generator completes Ila-b and Transporter completes 11c-e) a.Transporter's Name and Address: f , b. Phone: I c.Driver Name(Print) d.Signature e.Dale III. DESTINATION (Generator complete Ilia-c and Destination Site completes 111d-g) a. Disposal Facility and Site Address: c.US EPA Number d. Discrepancy Indication Space: b. I hereby certify that the above named material has been accepted avid to the best of m knowled a the foreqoing is true and accurate. ! e.Name of Authorized Agent Print f.Signature Date IV. ASBESTOS (Generator completes IVa-f and Operator complete-IV6117 a.Operator's Name and Address: c.Responsible Agency Name and Address: b.Phone: d.Phone: e.Special Handling Instructions and Additional Information: f.❑ Friable El Non-Friable 0 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 national governmental regulations. q.Operator's Name and Title Print h.Si nature 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 12110 GENERATOR RETAIN RS-F11A