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Qp""WREPUBLIC NOPOZARDOUS SPECIAL WASTE &OBESTOS MANIFEST <br />I10114 SERVICES <br />817496 If waste is asbestos waste, complete Sections 1, 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 <br />b. Manifest Document Number <br />c. Page 1 of <br />a / <br />lal has been accepted and to the best of my knowledge the foregoing is true and accurate. <br />.'Gen ators Name and I ation: �- <br />or� <br />e. Generator's Mailing Address <br />. Operator's Name and Title Print <br />, <br />f. Phone:' <br />g. Phone: <br />If owner of the ge era mg faality differs from the generator, provide: <br />h. Owner's Name: <br />I. Owners Phone No.: <br />j. Wast%Profile # <br />k. Exp. Date <br />I. Waste Shipping Name and <br />m. Containers <br />n. Total <br />o. Unit <br />No. <br />I Type <br />Description <br />Quantity <br />WtfVol <br />tr <br />L•� . <br />CJ <br />—e <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 actor ante with the requirements of 40 CFR 268 and is no longer a hazardous waste as defined by 40 CFR 261. <br />/ <br />Z—tp. <br />Y <br />Generator A orized •nt Name (Pont _ q. Si nature <br />r. Date <br />a. Transporter's Name and Address: <br />�14 ell <br />b. Phone: <br />c. Driver Name(Print) d. Signature e. Dat <br />- nr-c�TwwTrn�r /r]........,b.. .......nlele `Illo_n onil rloc}i ReTinrvRifc rmm�leTae Illri_ni <br />a. Disposal Facility and Site Address: <br />b. <br />c' US EPA Number <br />r' <br />d. Discrepancy Indication Space: <br />hereby certi that the ab a named mat <br />lal has been accepted and to the best of my knowledge the foregoing is true and accurate. <br />. Operator's Name and Title Print <br />e. Name of AuthorlzedA ent PrinlI <br />I i. Date <br />f. Si nature`" - <br />.Date <br />III AQRP62T(1S /r:anarafnr rmmnletes IVa -t and Unerator complete IVO -II <br />a. Operator's Name and Address: <br />b. Phone: <br />c. Responsible Agency Name and Address: <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 />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 12110 GENERATOR RETAIN RS-F11A <br />