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9WR� REPUBLIC NOGAZARDOUS SPECIAL WASTE ABESTOS MANIFEST ' -817494 If waste is asbestos waste, complete Sections I, II, III and IV If waste is NOT asbestos waste, complete Sections I, II and III 1. QIGrli k o nm P—, v ...... ....... a. Generator's US EPA ID Number- .... .r b. Manifest Document Number C. Page 1 of d. Generator's Name and Location: e. Generators Mailing Address: f. Phone: g. Phone: If owner of the generating facility differs from the generator, provide: h. Owners Name: i. Owner's Phone No.: j. Waste Profile # k. Exp. Date I. Waste Shipping Name and m. Containers n. Total o. Unit WtA/ol Descrtption No. Type Quantity g. Date ' 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 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 accordance with the requirements of 40 CFR 268 and is no longer a hazardous waste as defined by 40 CFR 261. 11 . Generator Authorized Agent Name Print . Signature r. Date II. TRANSPORTER Generator completes Ila -o ano i raps unel wniNicico a. Transporter's Name and Address: b. Phone: c. Driver Name Print d. Signature e. Date DESTINATION (Generator complete Ella -c ano uestlnatlon we cornpletes mu -y/ III. a. Disposal Facility and Site Address: c. US EPA Number d. Discrepancy Indication Space: b. I hereby certify that the above named material has been accepted and to the best of my knowled a the fore om is true and accurate. e. Name of Authorized Agent Print f: .Si nature g. Date ' — 11_ -..a,.. ......... i..a.... n/., f onrl rinPrntnr !`nMnlPto Rin -i) a. Operator's Name and Address: c. Responsible Agency Name and Address: b. Phone: d. Phone: e. Special Handling Instructions and Additional Information: I. ❑ Friable ❑ Non -Friable ❑ 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 classified, packaged, marked and labeled/placarded, and are in all respects in proper condition for transport according to applicable international and national governmental regulations. . O erator's Name and Title Print h. Si nature i. Date "Operator refers to the company whichowns, leases, operates, controls, or supervises the facility being demolished or renovated, or the demolition or renovation operation or both REV 12/10 GENERATOR RETAIN RS-F11A