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of 7)REPUBLIC NOWHAZARDOUS SPECIAL WASTE & ASBESTOS MANIFEST <br /> IS►� SERVICES <br /> If waste is asbestos waste,complete Sections I,II, III and IV <br /> IL r67 if waste is NOT asbestos waste,complete Sections I, II and III <br /> I. GENERATOR (Generator completes la-r) <br /> a. Generator's US EPA ID Number b. Manifest Document Number c.Page 1 of <br /> d. Generator's Name and Lpcation- e. Generator's Mailing Address: <br /> d+��" I I R 41V ►M� I���sr4� �9� fYl�l� �Tj'� #S <br /> f. Phone: '� Q 7 g• Phone: <br /> If owner of the generating facility differs if'orri the Lpe erdtor, provide: <br /> h. Owner's Name: i.Owner's Phone No.: <br /> j.Waste Profile# 77:_rxp. ,ate I.Waste Shipping Name and m.Containers n.Total o.Unit <br /> Description No. Type Quantity Wt/Vol <br /> �a �Y � 1 '5 0H � . 12,- 1 Q- It �Q A,b,�spa � � � �� Y <br /> GENERATOR'S CERTIFICATION: I hereby uc!lif`y 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 an o 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 uirements of 40 CFR 268 and is no Ior era hazardous waste as defined by 40 CFR 261. <br /> ,fir eSc�rA1 t 4)7- f 3 <br /> p. Generator A, <br /> orized Agent Name(Print) q.Signature r.Date <br /> ll. TRANSPORTER Generator;oT letes Iia-b and Trans oiler completes [Ic-e <br /> a.Transporter's Name and Address: 0wt <br /> k �� ��► g'i'rt rpl�t�+. �n�r+������,ef.. <br /> b- Phone: Y cly <br /> 1 <br /> i u- 1 v J' <br /> c. Driver Name(Print) d.Signature e. Date <br /> 111. DESTINATION (Generator complete Ilia-c and Destination Site completes 111d-g) <br /> a. Disposal 70-lity an�Add ss,sss: c.US EPA Number d.Discrepancy Indication Space: <br /> �l� S �fiw <br /> b. <br /> I he at the ove arced material has b n acce e t of my knowledge the regoing is tru cc e <br /> a e of wthorized Anent(Print f. i nature . Date <br /> IV. ASBESTOS (Generator complet Va-f andO plete IVg-i) <br /> a.Op rator's Name and Address: c. Responsible Agency Name and Address: qu CL(S.CMX"&-,L <br /> �J4G �� 3� �qi Cid 43725 Ph <br /> b. Phone: d. one: <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 th' 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 /> q. <br /> Al' <br /> Operator's Name and Title Print ]__h.SigiKure i.Date <br /> 'Operator refers to the company which owns,leases,operates,controls,or supefvises the facility being demolished or renovated,or the demolition or <br /> renovation operation or both <br /> REV 12/10 DESTINATION RETURN RS-F1 1A <br />