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,q5aLs- <br />/ oceo- <br />e. Date <br />/7 <br />41kr rir REPUBLIC" NON-HAZARDOUS SPECIAL WASTE & ASBESTOS MANIFEST <br />4,4 SERVICES <br />2566141 <br />If waste is asbestos waste, complete Sections I, II, III and IV <br />If waste is NOT asbestos waste, complete Sections I, II and III <br />GENERATOR Generator com letes la-r . . <br />a. Generator's US EPA ID Number <br />. <br />b. Manifest Document Number C. Page 1 of <br />d. G.enerators Name .and Location: <br />—.,... ..... ..... <br />1 ,f1., -11, "... ,:f.,!..;"'1•40;-;14 <br />..-- - <br />f. Phone: <br />e. Generators Mailing Address: <br />,. - • ^ - - • - ........ --....-......-. <br />g. Phone: <br />If owner of the generating facility differs from the generator, provide: <br />h. Owner's Name: i. Owner's Phone No.: <br />j. Waste Profile # k. Exp. Date I. Waste Shipping Name and <br />Description <br />m. Containers n. Total <br />Quantity <br />o. Unit <br />WI/Vol No. Type <br />.._ a ..L.f:, ; ,...... . 1 ...-...--..... ,...-:. <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 />1 imo-tk-i C•itI)A../- 74.;VV. ekat941" I 2. •-• 44 2. — 2.-satc <br />p. Generator Authdrized Agent Name (Print) q. Signature r. Date <br />TRANSPORTER (Generator completes ha-b and Transporter completes 11c-e <br />Transporters Name and Address: <br />k-ikko 4.=_AD <br />Phone: oc,-0,e7 <br />KAO? r"\ irl <br />d. Signature <br />a. Disposal Facility-and Site Address: . <br />... — — .-...—.....,.. <br />7''S„ <br />c. US EPA Number d. Discrep n cy. Indication Space: <br />i 7 I her erti 1 th.t th .1 e nand .t-rial has been accepted and to t e best of my kiloy4le e <br />• <br />../' <br />he fore cling is true and ac , rate. 1 -1........ <br />e. Name of Authorized Agent (Print) f. Signature g. Date <br />IV. ASBESTOS Generator completes IVa-f and 0 erat c.,iIhpiete IVg-i) <br />Operator's Name and Address: <br />Phone: <br />Responsible Agency Name and Address: <br />Phone: <br />Special Handling Instructions and Additional Information: <br />0 Friable 0 Non-Friable 0 Both % Friable ' % Non-Friable <br />OPER4TOR'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 governmental regulations. <br />Operator's Name and Title (Print) Signature I. Date <br />*Operator refers to the company which owns, leases, operates, controls, or supervises the facility being demolished or renovated, or the demolition or <br />renovation operation or both <br />c. Driver Name (Print) <br />DESTINATION Generator complete lila-c and Destination Site comp(e‘s Illd-g) <br />DESTINATION RETURN RS-F1 1A REV 04/19