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i REPUBLIC <br /> SERVICES N4N-HAZARDOUS SPECIAL WASTE & ASBESTAS MANIFEST <br /> If waste is asbestos waste,complete Sections I,it,III and IV <br /> If waste is NOT asbestos waste,complete Sections 1,11 and III <br /> I GENERATOR (Generator completes la-r) <br /> $ Generator s US EPA ID Number b.Manifest Document Number " <br /> Jc.Page 1 of <br /> d Gene-ratar's Mame and Location: <br /> e.Generator's Mailing Address: <br /> A04 3 F"no Ave <br /> if owner of the eneratin facili differs from the generator,f Phone: Q Phone t �A7 <br /> 9 g ty g erator,provide, <br /> i <br /> i h.Owner's Name: i.Owners Phone No. <br /> ' Waste Profile# �.......-�, ,....____.�____._ - ._ ,� �._ <br /> 1• k.Exp.Data I.Waste Shipping Nami and " m.Containers n.Total o.Unit <br /> ._ Descriction1 No. Type Quanta Wt/Vol <br /> r <br /> { . <br /> F <br /> a <br /> i <br /> I i <br /> GENERATOR'S CERTIFICATION• I hereby cert fyi that the above named mate eial is net 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 CM76azrid is na longer a hazardous waste as defined b 40 GFR Ztii. <br /> _ <br /> ^_•-__ .^-._—. .,,.-.«..,.. 4� <br /> Genitor Authorized Agent NamaPnntR �m <br /> S'np�tcir <br /> I r Date <br /> _ TRA►NSPflRTER Generator completfa-b and Transporter cotnptetes tic-e <br /> �a.Transporter's Name and Address: <br /> w , <br /> b Phone <br /> c [)river Name(print) <br /> ill DESTINATION (Generator complete lila-c and Destination Site completes iAd-g) <br /> a.Disposal Facility and Site Address. <br /> c.US EPA Number d.Discrepancy Indication Space: <br /> t ; <br /> -,.�-.v k..�.�.._..�.....-.... <br /> reb es of that the above named material has teen a and to the treat cf m knowled a the to oin is true and accurate. <br /> e ,ama of�orized nt Prinur <br /> t - - <br /> _.,_ ,_.._s_ i fr+ e7at <br /> IV. ASBESTOS (Generator completes tVa-f and Operator complete lVg-i) <br /> a.Operator's Name and Address: a Responsible Agency Name and Address: <br /> s b Phane. <br /> _._._.-...__ ,. i d.Phone: <br /> e.Special Handling Instntctions and Additional information: <br /> t' <br /> 1 f.[; Fr+able r N __._w <br /> on Friable . Both ._ '!a Friable, °lo 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 povemmental rufations. <br /> 4 � <br /> .._ rafor s Name and Title 1ftnb h Signature <br /> i.Dat <br /> Operator refers tothe company which owns,leasesoperates,contrefsrr r tapsrviees(the facility bang demolished or renovated,br tlrte demolition or <br /> L renovation operation or both <br /> REV 01•'14 <br /> RETURN TO GENERATOR R$+11A <br />