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gPID REPUBLIC NUN-HAZARDOUS SPECIAL WASTE & ASBESTOS MANIFEST <br /> J SERVICES <br /> If waste is asbestos waste,complete Sections 1,11,III and IV <br /> If waste is NOT asbestos waste,complete Sections 1,II and III <br /> t. GENERATOR (Generator completes la-r) <br /> a.Generator's US EPA IR Number b.Manifest Document Number s c. Page 1 of <br /> i } <br /> d.Generator'sF <br /> Name and Location: .. a.Generator's Mailing Address: <br /> I <br /> F <br /> �f Phone: <br /> if owner of the generating facility differs from the generator,provide. <br /> ` h Owner's Name: i.Owner's Phone No.: <br /> I <br /> _ <br /> } Waste Profile# ., k Exp Date 1.Waste Shipping Name and M.Co.C€iitainers : n.Total o.Unit <br /> ' Description �No. T e Quantity Wwol <br /> '��� i.e...�✓ r; ..jr r.. � <br /> E <br /> I <br /> state law,has been properly described,clay certify <br /> and packaged M_l _ ._.._�_ p <br /> waste is a treatment residue of s previously restricted haxkaged,and <br /> material isnot a hazardous waste as defined to p CFR e r u any appi cable <br /> GENERATOR'S CERTIFICATION, t hereb certi that the above named <br /> is�n proper condition for transportation according to applicable regulations.AND,if this <br /> to 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 6t ltd is no Inn era hazardous waste as defined by 40 CFR 261. <br /> --. <br /> _. A__ <br /> t p Genera o Authorrzed�A _snt Name tPnnt nah'"____ nate <br /> it, TRANSPORTER(Generator completes lla-b and Transporter completes iic�e <br /> { a.Transporter's Name and Address: <br /> I <br /> { <br /> i . Phone_ <br /> c Driver Name(Print d.S' nature <br /> . ._... - ,.._1 _ _ .:e.Date <br /> DESTINATION (Generator complete llla-c and Destination Site completes Illd-g) <br /> Fe.Disposal Facility and Site Address. c.US EPA Number d Discrepancy indication Space: <br /> b _ <br /> ! +erfib4 cert that the above named material rias t.-,--en accepted and to the best ofimknowtede the foregaifs is true and e. <br /> __._.. <br /> t <br /> e Name ofAuthonz Al nt,Pnnik f,S nal rs LL <br /> IV ASBESTOS (Generator completes 1Va-f and Operator complete IVg-1) <br /> p _ _... W __._._. <br /> a.Ope -- <br /> rator's Name and Address: c Responsible Agency Name and Address: <br /> i <br /> d. <br /> i <br /> t <br /> h Phone; i , <br /> .Special Handling Instructions and Additional Information. <br /> Friable 0 OPERATOR'S _Non finable ©Both__, to Friable %Non-Friable <br /> CERTIFICATION:I herebydeclare that the contents of this consignment a '� accurately e pro ng .. <br /> g are fully and described above by the proper shipping name; <br /> and are classified,packaged,marked and labelediplacarded,and are in all respects in proper condition for transport according to applicable International and ' <br /> national govemmental regulations.Y T <br /> _ _- <br /> Operator s Name and TitlexPr�nt� ... mho Sia�nature_�� � 'I.Date <br /> Operator refers to the company which owns,leases,o rates,coi cWis, enova "-r <br /> p P y pe �su�d+vis�s the facility being demolished or renovated,or the demolition or , <br /> renovation operation or botht <br /> REV 0114 RETURN TO GENE ATOR RS-F11A <br />