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IV. ASBESTOS (Generator completes IVa-f and Operator complete IVg-i) • PE'/ 0410 RS-FlIA I a GENERATOR RETAIN a Operator's Name and Address: ci ".' - . - .-i. Responsible Agency Name and Address: Phone: e S.z.t..: al Handling instructions and Additional Information: 0 Friable ;_i Non-Friable 0 Both % Friable % 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 and are Oassifiecl. packaged, marked and labeled/placarded, and are in all respects in proper condition for transport according to applicable international and national governmental regulations. Operator's Name and Title (Print) 1 h. Signature i. Date 'Operator refers to the company WhiCh owns, leases, operates, controls, or supervises the facility being demolished Or renovated, or the demolition or renovation operation or both • • • R., 04 REPUBLIC NON-HAZARDOUS SPECIAL WASTE & ASBESTOS MANIFEST dot% sEs as:e sas:estos m,aste, compete Sections I. U, Ill and IV I ...I. ...)b If wastes NOT asbestos waste. complete Sections I. II and III GENERATOR ,Generator completes la-r a. Generator's US EPA ID Number b. Manifest Document Number c. Page 1 of d. Generators Name and Location: I. Phone e Generators Mating Address: ' g. Phone: If owner of the generating faty differs from the generator, provide: Owner's Name: 1 Owner's Phone No.: Waste Profile* k. Exp. Date I. Waste Shipping Name and Description m. Containers n. Total Quantity o. Unit Wt/Vol No. Type 4ts:-..;,-7;-.1i.7 ,,,ts.-..... :-,.,., nal...:•<-2.,i. • GENERATORS CERTIFICATION! I hereby certify that the above named material is not a hazardous waste as defined by 40 CFR 261 or any applicable 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 acoxdance with the requirements of 40 CFR 268 and is no longer a hazardous waste as defined by 40 CFR 261. p. Generator Authorized Agent Name (Print) q. Sgpature r. Date c Driver Name rPrint) e Date d. Signature (Generator completes Ila-b and Transporter completes Ilc-e a Transponers tiafne arid Address b. Phone: DESTINATION (Generator complete Illa-c and Destination Site completes Illd • a Disposal Facility and Site Address: b c US EPA Number d. Discrepancy Indication Space. I hereby certify that the above named material has been accepted and to the best of my knowledge the foregoing is true and accurate. e Name cl A:iittiorized. Anent (Print) f. Sgnature g. Date • C. • • • • • • • •