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REPUBLIC NON-HAZARDOUS SPECIAL WASTE & ASBESTOS MA I T { <br /> -0 SERVICES <br /> t <br /> ff waste is asbestos waste,complete Sections I,II,111 and IV <br /> 1314754 If waste is NOT asbestos waste,complete Sections 1,11 and III <br /> 2 / q7�- <br /> 11. GENERATOR (Generator completes la-r) <br /> a.Generator's US EPA ID Number b.Manifest Document Number c.Pagel ,of <br /> IWA <br /> d.Generator's Name and Location: C U 7-rf (/ F A <br /> e.Generator's Mailing Address: <br /> f.Phone: 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,Wade Profile# k.Exp.Date I.Waste Shipping Name and m.Containers n.Total o.Unit t <br /> Description No. Type Quantity WtNol <br /> - C <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 I <br /> waste is a treatment residue of a previously restricted hazardous we-pbject 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 a ra i na to e-tmpr�ous waste as defined by 40 CFR 261. <br /> .- <br /> if <br /> eperator,Autbori ed Agent Name.(Print)- natu / r.Date �. <br /> t *'51 M§PblRtER Generator completV Ila- and Tfanspoyfer completes Ilc-e j <br /> a.Transpo�ter`s Name and Address <br /> .m (nnrP2 QJ Inc, <br /> r'.Q t3ux i57 <br /> b.Phone:Lod.,CA 172,41 <br /> c.Driver Name Print 1( Signature e.Date <br /> III. DESTIN ION(Generator complete Ilia-c and Destination Site completes 111d-g) <br /> a.Disposal Facility and Site Address: c.US EPA Number d.Discrepancy Indication Space: " <br /> 771 Lan&i <br /> V_*5 AuAn Rd ( I• '. <br /> b Manh-ca,QA k0d <br /> TT hereby certify that the above named material has*een..acce ted and to the best of my knowledge the foregoing is-true anr_acCurate. i -t' G" I <br /> e.Name of Authorized Agent Print f. nature a.Date f <br /> IV. ASBESTOS (Generator completes IVa-f and Operator complete lVg-i) I <br /> a.Operators Name and Address: c'Responsible Agency Name and Address: I( <br /> l <br /> b.Phone: d.Phone: <br /> e.Special Handling Instructions and Additional Information: r <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 i <br /> national governmental regulations. <br /> g.Operator's Name and TitlePrint h.Signature i. Date <br /> �l <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-F11A <br /> I <br />