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� R REPUBLIC NON-HAZARDOUS SPECIAL WASTE $ ASBESTOS MANIFEST <br /> SERVICES <br /> t• cA r 4 , r�2 if waste is asbestos waste,complete Sections 1,It,Ii I and IV <br /> 2_ 4 If waste is NOT asbestos waste,complete Sections I, II and III <br /> GENERATOR (Generator completes la-r) <br /> a.Generators US EPA ID Number b.Manifest Document Number c.Page 1 of <br /> d.Generator' Qlap2e pd Lin _ e.G ergWs.Maihng Address: <br /> ]L:c_1a! ?tS"i7��f£.A�alir�r,tInc <br /> .�. _ {fix <br /> _ :'c-gax3K Man E`"CA_ <br /> f. Phone; g. Phone: <br /> If owner of the generating facility differs from the generator,provide: <br /> h.Owners Name: `-err:er 3 � i.Owner's Phone Nd:twr—j r ' <br /> ;.Waste Profile# k.Exp. Date I.Waste Shipping Name and m. Containers n.Total a.Unit <br /> Description No. Type Quanti WtNol <br /> E E1Cii� u`t2 ==tom H1€ Non;riabiE <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 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 CFR 268 and is no longer a hazardous waste as defined by 40 CFR 261. <br /> r � <br /> 'enerator Authorized Agent Name(Print) q.Signature V V r. Date <br /> TRANSPORTER Generator completes lla-b and Transporter completes Ilc-e <br /> a.Transporter's Name and Address: <br /> b. Phone: <br /> c.Driver Name Pnnt d. igna!WLe. ate <br /> Ill. DESTINATION (Generator complete Illa-c and Destination Site completes 111d-g) <br /> a. Disposal Facilityand Site Address: c.US EPA Number d. Discrepancy Indication Space: <br /> \51 -�qS_AU_,'INRO�_t-lbiL - - xrsrvoi ��sa <br /> r t <br /> I fierciap ceiti that the above nam material h bees acceptarld tftthebest of my knowledge the for oin ' true diagc Mte , <br /> of Au1h6' r er t Print f.Signature I q.Dale1 f <br /> IV. ASBESTOS (Generator completes IVa-f and Operator complete IVg-i) <br /> a.Operator's Name and Address: c.Responsible Agency Name and Address: <br /> J <br /> b. Phone::ti`9! 21" d. Phone: <br /> e. Special Handling Instructions and Additional Information: <br /> SSSK.09—S24-0611 E_T_1t-,g N1JM ER1 A6-111 <br /> '.F't — <br /> f.❑ Friable b 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 /> ire classified, packaged, marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable international and <br /> rtal govemmental regulations. <br /> O erators Name and Title Print i nature i.Date <br /> 'Operator refers to the company which owns,leaself operatesoftntrols,or supervises the facility being demolished or renovated,or the demolition or <br /> renovation operation or both <br /> REV 01114 DESTINATiON2 RETURN RS-F11A <br />