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REPUBLIC NON-HAZARDOUS SPECIAL SERVICES WASTE & ASBESTOS MANIFEST '•7f if waste is asbestos waste,complete Sections I, II, III and fV 64 ')32t If waste is NOT asbestos waste,complete Sections I,If and Ill �• GENERATOR (Generator completes la-r) a. Generator's US EPA ID Number b. Manifest Document Number =C, e 1 of d. Generator's Name and Location: e. Generator's Mailing Address: f. Phone: g. Phone: If owner of the generating facility differs from the generator, provide: h. Owner's Name: i. Owner's Phone No.: j.Waste Profile# k, Exp. Date I.Waste Shipping Name and m. Containers n. Tota! o. Unit Desai tion No. T e Quantic Wt/Vol GENERATOR'S CERTIFICATION: I hereby certify that the above named materia!is nota 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. p. Generator Authorized Agent Name(Print) q. Signature r ❑ate II. TRANSPORTER Generator completes Ila-b and Transporter Completes 11c-ell a. Transporter's Name and Address: b. Phone: c. Driver Name Print d. Signature _ e. Date DESTINATION (Generator complete 111a-c and Destination Site completes 111d-g) a. Disposal Facikty and Site Address: c. US EPA Number d. Discrepancy Indication Space: b. I hereby certify that the above named material has been accepted and to the best of my knowledge the faregoinq is true and accurate. Le. Name of Authorized Agent Print f. Si nature IV. ASBESTOS (Generator completes IVa-f and Operator complete IVg-i) .Date a. Operator's Name and Address: c. Responsible Agency Name and Address: b. Phone: d. Phone: e. Special Handling Instructions and Additional Information: ppf Non-Friable % Friable %Non-Friable ERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name, packaged, marked and labeledlplacardodand are in all respects in proper condition for transport according to applicable international and ental 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 01114 GENERATOR RETAIN