Laserfiche WebLink
REPUBLIC NON-HAZARDOUS SPECIAL WASTE & ASBESTOS MANIFEST <br /> ` SERVICES <br /> r , <br /> If waste is asbestos waste,complete Sections I,Ii, III and IV <br /> p- If waste is NOT asbestos waste,complete Sections I,II and III <br /> �r <br /> I. GENERATOR (Generator completes la-r) <br /> a. Generator's US EPA ID Number b. Manifest Document Number c. Page 1 of <br /> ., d.Generator's Name and Location: e.Generator's Mailing Address: <br /> .n <br /> e , Y <br />{ },. f. Phone: g. Phone: <br /> N>�ws <br /> If owner of the generating facility differs from the generator,provide: <br /> h.Owner's Name: i.Owner's Phone No.: <br /> i j.Waste Profile# k. Exp.Date I.Waste Shipping Name and <br /> m.Containers n.Total o. Unit <br /> Description No. Type Quantity Wt/Vol <br /> w <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 /> p.Generator Authorized Agent Name(Print) q. Signature r. Date <br /> 11. TRANSPORTER Generator completes Ila-b and Transporter completes Ilc-e <br /> a.Transporter's Name and Address: <br />� b. Phone: <br /> c. Driver Name(Print) d.Signature e. Date <br /> III. DESTINATION (Generator complete Illa-c and Destination Site completes Illd-g) <br /> a.Disposal Facility and Site Address: c. US EPA Number d. Discrepancy Indication Space: <br /> b. <br /> I hereby certify that the above named material has been accepted and to the best of my knowledge the foing is true and accurate. <br /> e.Name of Authorized Agent Print f. Signature . Date <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 /> b.Phone: d. Phone: <br /> e.Special Handling Instructions and Additional information: <br /> f.0 Friable ❑ 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 /> and are dassifi®d,packaged,marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable international and <br /> national govemmental,regulations, <br /> ----------------- <br /> �? tors Name end Title Print h.Si nature <br /> r*rrefers to the company which owns,leases,operates,controls,or supervises the facility being demolisi. DhaFe <br /> ed or renovated,or the demolition or <br /> atkxt tion or both <br /> TRANSPORTER RETAIN <br /> - RS+1 IA <br />