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I&T <br /> REPUBLIC NON-HAZARDOUS SPECIAL WASTE & ASBESTOS MANIFEST <br /> �� l, SERVICES <br /> � � � � - If waste is asbestos waste,complete Sections t,II,IIE and IV <br /> d�1 If waste is NOT asbestos waste,complete Sections I,II and I II <br /> GENERATOR (Generator completes is-r) <br /> a.Generators US EPA ID Number b. Manifest Document Number c. Page 1 of <br /> k'A <br /> d.Genera ors Name and.Location: e. rate ailing Address: <br /> tPnr1L-3 5G,-.�01E4i`ri±i .'P Abrcw- �._-l�£2X�_ <br /> im_ ni'- Rd. % - 3455 3t7: r3.�A <br /> f. Phone: g.Phone: <br /> If owner of the generating facility differs from the generator,provide: <br /> h. Owner's Name: &W?7U A = c i.Owners Phone No.-�; ; <br /> j.Waste Profile# k. Exp.Date I. Waste Shipping Name and m.Containers n.Total o. Unit <br /> Description No. Tvpe Quantity Wt/Vol <br /> 0807 . <br /> GENERATOR'S CERTIFICATION: I hereby certify that the above named matenal 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 GFR 268 and is no longer a hazardous waste as defined by 40 CFR 261. <br /> �. a s = - 16 <br /> Generator Authorized Agent Name Print q. Signature r. Date <br /> TRANSPORTER Generator completes Ila-b 4dTransporter completes lice <br /> a.Transporters Name and Address: <br /> �" :irk. {` �i w.r __ � Y _ �Tf1�t=1J Avenue <br /> b. Phone: <br /> I MS3�0' 1 - - 1 <br /> c. river Name Print d. q6ture 2JZ e. Date <br /> Ill. DESTINATION (Generator comp) lla-c and Destination Site completes Ilid-g) <br /> a. Disposal Facility and Site Address: c. US EPA Number d. Discrepancy Indication Space: <br /> h by erti hove named material hw been a ce ted d th4 b t of my knowledge the for oin is ute and v rate. <br /> k, 51 V A ) 'I L_�ZZ z---- QL <br /> e of Authorize P nt f. Sin . Date <br /> IV. ASBEST S (Generator completes IVa-f and Operator complete Ng-i) <br /> a.Operators Name and Address: c.Responsible Agency Name and Address: <br /> I+#nrzGc� ntfta'�Choaf <br /> b. Phone:= d. Phone: - <br /> e.Special Handling Instructions and Additional Information: <br /> __ ,aCh°���:L.s,rs��!oti'�i��^Xtra:=wr!sc.T.f�t�zrama�t,�->c..Potti3ftic6rnr=�rss.iNods�,r:. 55asa,x34-51r1`���� E.T. �tt� i�I��,JtF�e=:1�-j.:� <br /> f.❑ Friable ' U Non-Friable ❑ Both %Friable l-`` %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 /> P-4 are classified,packaged,marked and tabeledlpiacarded,and are in all respects in proper condition for transport according to applicable international and <br /> Lal govern ntal ulations. <br /> Y),5". VOrw &_V� <br /> t <br /> rator s Name aI h. Sig6aVire i.Date <br /> 'Operator refers to the company which owns, leases,op r s,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 />