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5; 7;REPUBLIC N014AZARDOUS SPECIAL WASTE ABESTOS MANIFEST <br />* SERVICES <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 />I. GENERATOR (Generator conrDletes la -r) <br />a. Generator:s,U$ EPA ID Numb <br />b. Manifest Document Number <br />c. Pae 1 of <br />d. Generator's Name and Location: <br />e. Generator's Mailing Address: <br />,r <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 />f. Phone:Sfi E/k '(iF.J ,�,"-,"'. <br />g. Phone: <br />If owner of the generating facility differs from the generator, provide: <br />h. Owner's Name: <br />i. Owner's Phone No.: <br />_ <br />j. Waste Profile # <br />k. Exp. Date <br />I. Waste Shipping Name and <br />m. Containers <br />n. Total <br />o. Unit <br />No. <br />Type <br />Description <br />Quantity <br />f. Signature .Date <br />.Wt/Vol <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 Restrictionsf,ILcerttfy and warrant that the waste has <br />been treated iriaccordance with the requirements of 40 CFR 268 and is no longer hazardous waste as def d by 40 CFR 261. <br />R <br />. General r Authorized Agent Name (Print) <br />q. Sig p ature- ... <br />r. Date <br />It. TKANSPUKILK Venerator completes Ila -_I) and I ranS orter completes IIc-e <br />a. Transporter�S ^N;ame and dress: �:' �/�► <br />b. Phone: 61 e :" Y /'an^"- -..L <br />c. Driver Nam (Print)-' I d. Signature e. Date <br />III. DESTINATION (Generator complete,111a-c and Destination Site completes Illd-g) <br />a. Dis_osal Facility and Site Address: <br />_ % <br />c. US EPA -Number <br />d. Discrepancy Indication Space: <br />e. Special Handling Instructions and Additional Information: <br />,r <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 <br />h. Signature <br />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 />b. <br />I hereby certify that the above named <br />material has been accepted and to the best of my knowled a the fore oin is true and accurate. <br />e. Name of Authorized Agent Print <br />f. Signature .Date <br />IV. ASBESTOS (Generator completes lVa-f and Operator complete IVg-i) <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 % 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 <br />h. Signature <br />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 />I <br />REV 12/10 GENERATOR RETAIN RS-F11A <br />