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of REPUBLIC Nt&AZARDOUS SPECIAL WASTE `SBES,TOS MANIFEST <br />SERVICES <br />869335 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. enerator's US /6 EPA IM,, <br />i <br />b. Manifest Document Number <br />c. Page 1 of <br />d. Generator's Name and Location: <br />cS�.✓ lJ t L L Witt STeek len/ LL G <br />f. Phone: Q <br />e. Generator's Mailing Address: <br />,-3 2- O 3co <br />g. Phone: 7 yo .57'w"57 <br />If owner of the generating facility c7iffers from the generator, provide: <br />h. Owner's Name: <br />I. 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 LO <br />o. Unit <br />Wt/Vol <br />No. <br />Type <br />�� oyiy//o9 <br />/-Zz-/s <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 longe hazardo s waste as defined by 40 CFR 261. <br />. Generator Authorized Agent Name Print <br />. Signature <br />r. Date <br />Ila -D ana <br />a. Trans iters Name and Address: <br />c�/i1) �iYD�'�'� O/L /.JG, /�d �,Z PX I � Com. 9SLS/ <br />. or! d. Signature I e. Date <br />DESTINATIO enerator comDlete Illa-c and Destination Site completes Illd-al <br />a. Disposal Facility and Site Address: <br />999 q 3, i2 <br />b. 1-0 /—T CA CA?- 9 <br />c. US EPA Number <br />d. Discrepancy Indication Space: <br />I hereby certify that the above named material has been accepted and to the bestof my knowled a the foregoing is true and accurate. <br />f. ❑ Friable ❑ Non -Friable ❑ Both % Friable % Non -Friable <br />-. <br />S , <br />e. Name of Authorized Agent Print <br />f. Signature g. Date <br />IV. ASBESTOS (Generator completes IVa -f and Operator complete IVq-i) <br />a. Operators 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 h. 5ignatue.e J L <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 />F3 <br />REV 12/10 RETURN TO OPERATOR RS-F11A <br />