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�R'tA REPUBLIC NON-HAZARDOUS SPECIAL WASTE & ASBESTOS MANIFEST <br /> ,\ 40,44 SERVICES <br /> 21 42477 <br /> t q 7 If waste is asbestos waste,complete Sections I, II,111 and IV <br /> [} L} i if waste is NOT asbestos waste,complete Sections 1,II and III <br /> GENERATOR (Generator completes la-r) <br /> a. Generator's US EPA ID Number b.Manifest Document Numberc. Page 1 of <br /> .! '1A, -7T 1 <br /> d. Geneame e. tar' ailing Address: <br /> -A�Is-r:-j Ei:4r4n.antft. �'- !. X� <br /> CA Ata_i 3 <br /> f. Phone: `-- _ ____ g.Phone: <br /> If owner of the generating facility differs from the generator,provide: <br /> h. Owner's Name: G i-er s zma 1.Owner's Phone NoV`wner FF <br /> j.Waste Profile# k.Exp. Date I.Waste ShippkV Name and M. Contairws n.Total o.Unit <br /> {w �C <br /> DescriptionWi, r /♦,No. T Quanttty Wtivol <br /> • � <br /> GENERATOR'S CERTIFICATION: I hereby certify that the above named material is not a hazardous waste as defined by 40 GFR 261 or any applicable <br /> state law, has been property 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 Vo longer a hazardous waste as defined b 40 CFR 261. <br /> r: { la -lam <br /> generator Authorized Agent Name Print Q. SignaturY I r.Date <br /> TRANSPORTER Generator completes Ila-b and Trans orter Completes Ilc-e <br /> a.Transporters Name and Address: <br /> i=fPlcfciJ A <br /> b. P ne: <br /> Lc. Driver Na a Print . Sin re e.Date <br /> 111. DESTINATION (Generator complete Illa-c and Destination Site completes 111d-g) <br /> a. Dis al Facility and Site Address: c. US EPA Number d. Discrepancy Indication Space: <br /> =''} 'sem - f'.. E i. -.?�iS A, � <br /> I th4lbove named material has been aboe to The t of m knowl a the foreqoinq isftd and bccurath. <br /> e. Name of AuthorizedA t t f.Si n ture j .Date <br /> IV. ASBEST (Generator completes [Va-rml Operator complete IVg-i) r <br /> a.Operator's Name and Address: c. Responsible Agency Name and Address:` <br /> "Aantara Usti g 5cha Mt akx'_` p+ <br /> b. Phone:: 5,F S`-�L:Se <br /> H Phone: <br /> e.Special Handling Instructions and Additional Information: <br /> Darz, 2.-t,p2mav7 r.'r,C7»Ir i5 E7-41.... Pusi 7PTl].@ax 595£,r14] i:'G. J0. SS352, r:-T-20S <br /> f.❑ Friable 0 Non-Friable ❑ Both %Friabie `- %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 labeledlplacarded,and are in all respects in proper condition for transport according to applicable international and <br /> ial ovemmental r ulations. <br /> 1 1, 4 - <br /> q. tor Name and Title Print . Si r i-Date <br /> 'Operator refers to the company which owns,lease-9,opetates,controls,or supervises the facility being demolished or renovated,or the demolition or <br /> renovation operation or both <br /> REV 01114 OESTINA.TION RETURN RS-F11A <br />