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a>s�rw®a.inr nvry MAZKWU8 SPECIAL WASTE $ ASBESTOS MANIFEST <br /> SERVICES <br /> ES <br /> 621688 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 /> I• GENERATOR (Generator completes la-r) <br /> ( a.Generators US EPA ID Number b. Manifest Document Number <br /> c.Page t of <br /> d. Generator's Name and Location: e. ^eneratora Mailing Address: <br /> f. Phone: - ' ' a . Phone: . <br /> If owner of the generating facility df rs 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 n n.Total o. UnitDescH bon No. T e Quantity WI/Vol <br /> GENERATOR'S CERTIFICATION: I hereby certify that the above named material Is not a hazardous waste as dented by 40 CFR 261 or any applicable <br /> state low,has been properly described, classified and packaged,and is in proper condition for transportation according to applicable regulations;AND,If this <br /> waste 4 a treatment residue of a previously restricted hazardous waste subject to the Land Disposal Restrictions. 1 certify and warrant that the waste hes <br /> been treated in accordance with the requirements of 40 CFR 268 and Is no Ion sr a hazardous waste as defined by 40 CFR 261. <br /> p.GeneratorAuq-e�tName Hnt .Si nature I r.D Dgr? 7 <br /> Ii. TRAN P TWR (Gongretor com f 1141-b and Transplarter oompletse lice <br /> B:Transporter's Name and Address. <br /> `r r <br /> b. <br /> Phone: flj r <br /> c.Driver Name Print d.Si natureI e.Data <br /> M. DESTINATION (Generator complete Illa-c and Destination Site completes Illd-g) <br /> a.Disposal Facility and Site Address: a US EPA Number d. Discrepancy Indication Space: <br /> b. <br /> I hereby cartIN that the ebov named material has been ecce Rad and to-the best of my as the fo oIng is true and accurate. <br /> a.Name of Authorized Agent Print f. signature .Oats <br /> IV. ASBESTOS (Generator completes IVa-f and Operator complete IVa-f) <br /> a.Operator's Name and Address: c.Responsible Agency Name and Address: <br /> b. Phone: I d Phone <br /> e Special Handling Instructions and Additional Information. <br /> F Non- Ha Is Bo ° Friable NLhion-Fdabiv <br /> OPERATOR'S CERTIFICA ION:I hereby declare that the contents of this consignment are Rifly and accurately described above by the proper shipping name <br /> and aro cil"Wed,packaged,marked and Iabeled/plecarded,and are In all respects in proper condition for transport according to applicable international and <br /> national governmental regulations. <br /> JbO Norris n Title Pdnt h. n r I. to <br /> perlNor re M the company which owns, leasee,operates,controls,or supervises the facility being demolished or renovated,or th <br /> ne demolition or <br /> renovatiooperation or both <br /> �Ev 12/10 GENERATOR RETAIN RS-F11A <br />