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�T- <br /> t9LPW AUG NON-1=1AZZARDOUy SPECIAL WASTE 8, ASBESTOS MANIFEST <br /> ^�^ SERVICES <br /> �l <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 completes Ia-r) 1•. <br /> a.Geneiator's US EPA ID Number b.Manifest Document Number c.Page 1 of <br /> d.Generator's Name and Location: e.Generator's Malling Address: <br /> „ <br /> f.Phone: !I g.Phone: <br /> If owner of the generating facility differs from the generator,provide: <br /> h.Owner's Name: I.Owner's Phone No.: <br /> j.Waste Profile# k.Exp.Date I.Waste Shipping Name and m.Conlainers n.Total o.Unit <br /> Description No. Type Quantic WI/Vol <br /> GFNFRATOR'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 266 and Is no longer a hazardous waste as defined by 40 CFR 261. <br /> Generator Authorized Agent Name Print S.Signature r.Date <br /> II, TRANSPORTER (Generator completes Ila-b and Transporter completes lic-e) <br /> a.Transporter's Name and Address: <br /> b. Phone: <br /> c.Driver Name(Print) d:SI nature _ e.Date <br /> III. DESTINATION (Generator complete Ilia-c and Destination Site completes Illd-g) <br /> a.Disposal Facility and Site Address: c.US FPA Number d.Discrepancy Indication Space: <br /> b. ( I <br /> I hereby cerlif thWthe above named material has been acce led'and to the best of my knowledge the foregolng is true and accbrate. i 1 <br /> i <br /> eme of Authorized Agent Print f.Si naluro Date <br /> .Na <br /> IV. ASBESTOS (Generator completes IVa-f and Operator complete ]Vg-i) <br /> a.Operator's Name and Address: c.Responsible Agency Name and Address: <br /> b.Phone: d.Phone: RECL111 " <br /> e.Special Handling Instructions and Additional Information: <br /> w 1 <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 Itn rtracc rding to applijaflrl International and <br /> national governmental regulations. I�U4( U �i��I\ <br /> - EPART MENIT <br /> g.Operator's Name and Title Print h.Signature 1 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 o station or bolsi <br /> REV 01/14 R5-F11A <br />