Laserfiche WebLink
�A� REPUBLIC NONHAZARDOUS SPECIAL WASTE & ASBESTOS MANIFEST <br /> SERVICES <br /> If waste is asbestos waste,complete Sections I.II, 111 and IV <br /> 4457736 <br /> If waste is NOT asbestos waste,complete Sections 1, II and III <br /> 1. GENERATOR (Generator completes is-r) <br /> a.Generator's US EPA ID Number b.Manifest Document Number c.Page 1 of <br /> d.Generator's Name and Location: e.Generator's Mailing Address: <br /> _ <br /> .'i2 hi-jdtIs?i?i}I I i — If i£'I �I'ii#i L;fi'v <br /> f. Phone .r: rg"r;r,.CA -OP52.n ��`� =_��_�� g.Phone: �r J,HKA1 _d -- - <br /> If owner of the generating facility differs from the generator,provide. `_=3 r{:� -17 C R <br /> h.Owner's Name: i.Owner's Phone No.: <br /> j.Waste Profile# k.Exp_ Date 1.Waste Shipping Name and M.Containers n.Total o. Unit <br /> Description No. Type Quantity Wt/Vol <br /> iF <br /> i <br /> 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 <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 CFIR 26a and is no Ion er a hazardous waste as defined by 40 CFR 261. <br /> Generator Authorized A ent Name(Print) q. Signature r Date11. TRANSPORTER (Generator com letes Ila-b and Transporter com fetes Ilc-e <br /> I I a.Transporter's Name and Address- <br /> IRkA <br /> 6.Phone=. c, , 574L <br /> L <br /> c.Driver Name Print d.Si mature <br /> A�Date i <br /> III. DESTINATION (Generator complete illa-c and Destination Site completes illd-g) <br /> a Disposal Faelrty and Site Address: c-US EPA Number d. Discrepancy Indication Space_ <br /> e <br /> b. <br /> l hereby cerffy that the above named material has beery acre tend and to the best of m. knowle a the face of. is true and aemrate~ <br /> e_Name of Authorized Agent jPnrinjt L Si• re Date <br /> W. ASBESTOS (Generator completes Wa-t and Operator complete I g, <br /> EPhone: <br /> Nameand Address c R'espassid de Agency BVom and Addresm <br /> d8_Fttmrte <br /> lbstructons and Add#iotrali lhi orrmatimn, <br /> m-FriaiSl'e D� Bath %6 Friat�b °,lfv INam`Friebte: - <br /> OiPERAT CERTIFICATID ,R hereby dedlare-that.tthe canrdlea b ar>;tbie cons%pwag are:*AV amd accwAWV desimlhed altm by Vhe pmpen sNriplpimgp <br /> and are¢Iessifiedl,,packaged,mraAed and,43lbelis&0lacaode4 amd we in all respects um puoW cmardfdaim 11" ao ttm <br /> matimmaG gouermmentaf reg0aba iris, �fmftmmatlmmiall zad <br /> eratads:INemeancEliiti'e•Prom ' LSD. re a � <br /> "Operator msfers;to hire cefanpanyr wfniclh❑vans,lieases.,ap�eaates,,e�rmYrrarl;m„as sntperaisea the iracil'rL'y�rgp atlemacslislh�ll mr raft„mu tlhe atlemomlii5mm�am remmvafiom�o eraiaionn csr IrnGcrttn <br /> REV U1114 i <br /> DESTINATION RETURN Rs-F1TA <br />