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REPUBLIC NON-HAZARDOUS SPECIAL WASTE & ASBESTOS MANIFEST �V SERVICES p r! If waste is asbestos waste,complete Sections I, II,111 and IV 3130785 If waste is NOT asbestos waste,complete Sections I,II and 111 GENERATOR (Generator completes la-r) a. Generators US EPA ID Number b. Manifest Document Number C.Page 1 of d. Generators Name and Location: e. Generators Mailing Address: '-A SO 7EECS T - fr, _ q �CiTac�'v f. Phone: - g. Phone: If owner of the generating facility differs from the generator, provide: I 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. TXpe Quantity Wtivol --to a&,=9,:. 19 GENERATOR'S CERTIFICATION: I hereby certify that the above named material is not a hazardous waste as defined by 40 CFR 261 or any cip:,Ii-able 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 266,and is no longer a hazar to as defined by 40 CFR 261. t"Ira L�� 7 . �l� G -. C r Generator uthor zed A ent Name (Print . Si• ature I r. Date TRANSPORTER Generator corn lets Ila-b and Transporter completes Ilc-e a.Transporter's Name and Address: b_ Phone: c. Driver Name Print 'i ature I e. Date III. DESTINATION (Generator complete Ifla-c and Destination Site completes Illd-g) a. Di9posal Facility and Site Address: i C. US EPA Number d. Discrepancy Indication Space: :A,r•r -Sin CRI 0;10 L Z:l :. b. I h re ti rtify that e ab&e nam6d material has aen accepted and to the best of my knowledge the€ore oin is true and urate. JJJ .`� k 1 J� e.vgame?<of Authorize int rent f:. nature Date 1. IVB O `(Gel era r'- es Va-f and Operator cordte iVg-i) t. I a.Operators Name and Address: f c. Responsible Agency Name and Address: - -- - _ - X4'3-•Cic? -_ _ _?_ b. Phone: '-- d. Phone: e. Special dandling Insbuaons and Additional Information: . _- __:3rR �fnc.,PL+C's =Wx=450,Nt past,;. 3�352,IC?-_moi-s C1� 17. _'5 f.❑ Friable ❑ Non-Friable ❑ Both % Friable I % 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 i are classified, packaged, marked and labelec/piacarded,and are in all respects in proper condition for transport according to applicable international and mal governmental regulations. o. O erator s Name and This Print h. 5 tore i. Date 'Operator refers to the company which owns,ieases,ops—rates controls,or supervises the facility being demolished or renovated,or the demolition or renovation operation or both REV t]iH4 D-S71NATIO RETURN l RS-F 11 A