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R <br /> Q; W. REPUBLIC' NON-HAZARDOUS SPECIAL WASTE & ASBESTOS MANIFEST <br /> 114 SERVICES <br /> If waste is asbestos waste,complete Sections 1,11,111 and IV <br /> 6352293 �f waste is NOT asbestos waste,complete Sections 1, 11 and III <br /> I. GENERATOR (Generator completes la-r) <br /> a.Generator's US EPA ID Number b. Manifest Document Number c. Page I of <br /> NA <br /> d.Generator's Name and Location: e.Generator's Mailing Address: <br /> As;si>ciaieo'i moor setvice jrw Assocrale(I i ractot,_-�iervic-e irw-. <br /> 132-4-(jharier Way 'j,`23 t0harter way <br /> f. Phone: QfAAf�n ('A 09'M 1910 Arlg"Afinl�j <br /> 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.Containers n.Total o.Unit <br /> Description No. Type Quantity Wt/Vol <br /> 4442MC �11 1120221 Sod 10 <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 <br /> waste Is a treatment residue of a previously restricted hazardous was ubject to the Land Disposal Restrictions. I certify and warrant that the waste has <br /> beken treated in accordance with the reqpirements of 40 CF LR 268 a . s n er a hazardous waste as fined by 40 CFR 261. <br /> L4 Ir4 - <br /> fie, <br /> 7 <br /> p.Generator ALAhorized Agent Name(Print) 14"lignaturp- r. Date <br /> II. TRANSPORTER (Generator completes Ila-b and Transporter compVes llc-e) <br /> a.Transporter's Name and Address: <br /> b. Phone: <br /> c.DriyQermLe(Print) d. SiLaMaftrrg-7 e. Date <br /> Ill. DESTINATION (Generator complete Illa-c and DE-?S-"Ii nation Site, completes Illd-g) .4 <br /> a.Disposal Facility and Site Address: c. US EP Number d. D crepancy Indication Space: <br /> Forward Landfili <br /> s.AminRd. <br /> b. fvla-nlecaCA Z' 2C&rAQ­QX,#b <br /> I hereby certify that the named material has been accepted and to the bLest of mowledge the fare goinj4&-truQ#V <br /> 4&tr#V cc <br /> e.Name of AuthorlAgett(Print) f.Si tore to ...... <br /> IV. ASB-h'+OS Generator completes e lete lVg-) <br /> �x II <br /> a.Operator's NAddress:e and Aildress: c. Re p nsl a Agency Name and <br /> b.Phone: Phone: <br /> e.Special Handling Instructions and Additional Information: <br /> f.[I Friable D Non-Friable C1 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 intemational and <br /> national governmental regulations. I <br /> g.Operat r's Name and Title Print h.Si nature 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 operation or both <br /> REV 01114 DESTINATION RETURN RS-F11A <br />