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REPUBLIC <br />SERVICES <br />817493 <br />NO,*Z.ARDOUS SPECIAL WASTE &•BESTOS MANIFEST <br />If waste is asbestos waste, complete Sections I, ll, III and IV <br />If waste is NOT asbestos waste, complete Sections I, II and III <br />.z eucoeTnoI,rl <br />a. Gen tor's US EPA ID Number <br />b. Manifest Document Number <br />C. Page 1 of <br />d. Generator's Name and Location: <br />'e <br />f. Phone: <br />e. Generator's Mailing Address: <br />g. Phone: <br />If owner of the generating facility differs from the generator, provide: <br />h. Owner's Name: <br />L Owner's Phone No.: <br />j. Waste Profile # <br />k. Exp. Date <br />I. Waste Shipping Name and <br />Description <br />m. Containers <br />n. Total <br />Quantity <br />o. Unit <br />Wt/Vol <br />No. <br />Type <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 />p. Generator Authorized Agent Name Print <br />. Signature <br />r. Date <br />II. TRANISPOKI tK lienerator completes iia -o anu I rens UrrGl W1 I IIJVLWo m. -o <br />a. Transporter's Name and Address: <br />b. Phone: <br />c. Driver Name Print d. Signature e. Date <br />tTT��\K�i�1���Y Y.ral.�j�( -e y- TjraTa�T{U: I:CJI.r'AS>rLI1LNi-1-'nllNILIMln\It:iM.1111M erea•1 <br />a! Disposal Facility and Site Address:. c. US EPA Number d. Discrepancy Indication Space: <br />i <br />b. Phone: <br />i <br />b. <br />I hereby certq that the above named material has been accepted and to the best of my knowled a the fore om Is true and accurate. <br />i <br />I <br />e. Name of Authorized Agent Print <br />I. Signature I <br />Date <br />a. Operator's Name and Address: —' <br />c. Responsible Agency Name and Address: <br />b. Phone: <br />d. Phone: <br />e. Special Handling Instructions and Additional Information: <br />f. ❑ Friable ❑ Non -Friable ❑ Both % Friable e/ Non -Friable <br />OPERATOR'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 h. Signature I 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 />REV 12/10 GENERATOR RETAIN RS-F11A <br />