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REPUBLIC NON HAZARDOUS SPECIAL WASTE.&Ab.sESTOS MANIFEST �
<br /> i SERVICES v .
<br /> If waste is asbestos waste,complete Sections I,II„III and IV
<br /> �13147°53
<br /> If waste is NOT asbestos waste,complete Sections I,11 and III:
<br /> GENERATOR (Generator completes la-r) -
<br /> `9a,Generator's US EPA ID Number b.Manifest Document Number c.Page
<br /> d:Generator s Name and,------Location: e.Generator's Mailing Address:
<br /> ,z t'6(NI ,� C
<br /> 7 U ' g.Phone: Irz
<br /> CWil
<br /> �.G G ,e J
<br /> Is
<br /> If swner of,thegenerating facility dif fens from the generator,provide: I'
<br /> s &ihr s Narne- i.Owner's Phone No::
<br /> Ytfasfe Ptirofile# k.Exp.Date I.Waste Shipping Name and m Containers n.Total o.-Unit'.
<br /> j
<br /> / Description/ {_ ;.,.'f Type menti fWt/Vo 11
<br /> I {� No--, i�, QI *ham
<br /> 6
<br /> So
<br /> G ;CIEZS CERTJFICATiOPL I hereby certify that the above named material is not a hazardous waste as defined by 40 CFR 261'or any applicable,
<br /> state taw,has been property 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 ubject to the,L�and Disposal Restr,Ictions:=I ertify and.warrant`that-the.waste^has"^�7
<br /> .Mv
<br /> been treated in accordanceswith the,reguire_edhW&ff 0 t FR�L6-ren I°o lqn' r ous waste as defined b 40 CFR 261.
<br /> VIA '
<br /> f
<br /> p - ,Agent Name(Print) q. nat r Date
<br /> TRANSPORTER (Generator coin le Ila- and T s orte om letes,ilc-e
<br /> a.Transporters Name and Address ✓,
<br /> !tin Thom Oil Inc.
<br /> P 0.Box,K77,
<br /> b.Phone:Ludt,GA 95249
<br /> s r y
<br /> c:Dnver Name Print �fi ��jy2%j } .,d.Signature e.Date f ff <
<br /> illi DESTINATTdN (Generate�omplete Ills-c and Destination Site completes Illd-g)
<br /> a flwsposat FaciRyand Site Address: c.US EPA Number d.Discrepancy Indication Spacer
<br /> 9999 S.ALMn Rd
<br /> fc4 C f t r.
<br /> b Monier a,..CA 9b33zt ..� P :. y ..1: _. ,, .,-..•� -- -a-�-e-.�- ---- ..a
<br /> �1',hereb cern that the above named rriaferial Iia been acce ted and:to the bes.of ni kno ed a the foregoing is'trueand,a curate. :
<br /> r
<br /> e.Name of Authorized Agent Print f.Si 'nature /` { Date
<br /> I
<br /> IV.- _,,-,ASBESTOS (Generator completes-We--and Aerator qoiTlplete IVg-i)• f ✓. ' ,� '; ; 1��
<br /> a.Operaiar's Name and Address: TResponsible Agency Name and Address`.
<br /> b.Phone: 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 1
<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., j
<br /> Operator's Name and Title Print h.Signature i.Date I!
<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 12/10 RETURN TO OPERATOR ' RS-F1 1A 1�
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