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ewREPUBLIC NOI+AZARDOUS SPECIAL WASTE BIOBESTOS MANIFEST 44 d. Ge r r' `.o�ame and Location: zz f. Phone: :. c',A •'a-.. .'7 Y *SERVICES 8 1 - 4 9 -, If waste is asbestos waste, complete Sections I, II, III and IV I I. Owner's Phone No.: If waste is NOT asbestos waste, complete Sections I, II and III I. GENERATOR (Generator completes la -r) a. Generator's US EPA ID Nurr�ter b. Manifest Document Number c. Page 1 of d. Ge r r' `.o�ame and Location: zz f. Phone: :. c',A •'a-.. .'7 Y ' e. Generators Mailing Address: "7 j,� iesid v a Iry g. Phone: If owner of the generating facility differs from the generator, provide: h. Owner's Name: I I. Owner's Phone No.: j. Waste Profile # k. Exp. Date I. Waste Shipping Name and Description m. Containers . Operator's Name and Title Print n. Total Quantity o. Unit WWol No. Type e. Name of Autho ed Agent Print f. Sf nature . 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. . Generator Authorized Agent Name Print q. Signature i I r. Date II. 1 KANbt-UKI tK Iuenerator compietes ua-u ane I rains urlei uuin feces uu-e a. Transporter's..�J?ma and .Add-clress: b. Phone: c unver rvame briny �. oiynaiuio i In n I=QTIIdATIf11d lf-`.pnaratnr nri nantinatinn Ritp rmmnlptp.0 IIIA -O) a. Dispgsal Facility and Site Address: c. US EPA Number d. Discrepancy Indication Space: d. Phone: e. Special Handling Instructions and Additional Information: f. ❑ 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. . Operator's Name and Title Print b. i. Date ' `Operator refers to the company which owns, leases, operates, controls, or supervises the facility being demolished or renovated, or the demolition or I hereby certify that the above named material has been acre ted a - to0e b t of m owled a the foregoing is true a1qccuro. e. Name of Autho ed Agent Print f. Sf nature . Date IV AQRFCTOq f('pnprntnr rmmnlatpc IVa -f and Onerntor complete IVa -i) a. Operator's Name and Address: c. Responsible Agency Name and Address: b. Phone: d. Phone: e. Special Handling Instructions and Additional Information: f. ❑ 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. . Operator's Name and Title Print h. Signature i. Date ' `Operator refers to the company which owns, leases, operates, controls, or supervises the facility being demolished or renovated, or the demolition or renovation operation or both REV 12110 GENERATOR RETAIN RS-F11A