|
)
<br />(GeneratorIII DESTINATION complete lila-c and Destination-Site completes Illd-
<br />r, t
<br />Drive(Name (Print) d. Sign ture_
<br />r"-
<br />a. Date
<br />("T REPUBLIC NON-HAZARDOUS SPECIAL WASTE & ASBESTOS MANIFEST SERVICES
<br />ekt
<br />If waste Is asbestos waste, complete Sections I, II, Ill and IV
<br />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
<br />1 (.1, 01,,k.
<br />.. • \
<br />‘ , - • l'. i 1
<br />—..............at LAJleU1111,11t
<br />' '( , („
<br />ilurnoer c. Page 1 of
<br />_•4•
<br />I d. Generator's Name and Location:"
<br />:XL ( ::-0..,
<br />
<br />lei _,., \ , .
<br />
<br />f. Phone:.'''''‘ \, ' p-,
<br />e. Generator's Mailing Address:
<br />I .
<br />I , • r,,,. , II.. i
<br />9. Phone. . , . If owner of the genf e mg facility differs from-the generator, provide:
<br />h. Owner's Name: i. Owner's Phone No.: j. Waste Profile # k. Exp. Date I. Waste Shipping Name and
<br />Description
<br />m. Containers n. Total
<br />Quantity
<br />o. Unit
<br />WtNol No. Type
<br />, '--1 't 1 ‘‘ ' ) ! ) 7 11
<br />i ) ,
<br />' I , ' '
<br />I I • : 1
<br />r '
<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 CFR 268 and is no longer a hazardous waste-as defined by 40 CFR 261. ..
<br />.) ( V , \ , i f , • , — ‘ 1, ) hi: ) 1
<br />p. Generitor'Authorized AgenNa e (Print)- - o. Sig alum/ r. Date
<br />TRANSPORTER (Generator completes Ila-b and Transporter completes lic-e
<br />a. Transporter's Name and Address: , ••: 1 4 - Pitt. C4.a! •
<br />1 's;t„
<br />b. Phone:
<br /> i
<br /> ,
<br />--- .
<br />Disposal Facility and Site Address:
<br />t ;
<br />.
<br />C. US EPA Number d. Discrepancy Indication Space:
<br />I hereby certi_Nlhat the above named material has peen accepted and to the best of my knowledge the foregoing Is hue and accurate, i
<br />i 0 '•
<br />I r
<br />i ,
<br />`,.__. . .
<br />K
<br />i i 1
<br />4. Namb.of Authorized Agent (Print)
<br />- - 1 f. Signature Ls. Date
<br />. . .. . .,
<br />M - ASBESTOS (Generator completes lVa-f and Operator complete -
<br />c, Responsible Agency Name and Address: a. Operator's Name and Address:
<br />d. Phone: 'P one:
<br />dal Handling Instructions and Additional Information:
<br />a Ii Non-Friable 0 Both % Friable % Non-Friable
<br />RV CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the prow shipping mins
<br />Med, packaged, marked and labeiewpiacarded, and are In all respects In proper condition for transport according to appflostgs Mfamillionai end
<br />mantel regulations.
<br />Ite-Ft1h
<br />10 the company which owns, leases, oparatea, controls, or supervises the facility being demoilif) renevetad. or dornolnkm IPZ and Title (Print) h. Signeture or
<br />or both
<br />RETURN TO OPERATOR
|