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�R� REPUBLIC NON-HAZARDOUS SPECIAL WASTE & ASBESTOS MANIFEST SERVICES If waste is asbestos waste,complete Sections I,II,III and IV If waste is NOT asbestos waste,complete Sections I,II and III I. GENERATOR (Generator completes la-r) a.Generator's US EPA ID Number b.Manifest Document Number c.Page 1 of d.Generator's Name and Location: e.Generator's Mailing Address: f. Phone: g. Phone: If owner of the generating facility differs from the generator,provide: h.Owner's Name: i.Owner's Phone No.: j.Waste Profile# k.Exp.Date I.Waste Shipping Name and m.Containers n.Total o.Unit Description No. Type Quantity Wt/Vol 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 state law,has been properly described,classified and packaged,and is in proper condition for transportation according to applicable regulations;AND,if this 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 been treated in accordance with the requirements of 40 CFR 268 and is no Ion era hazardous waste as defined b 40 CFR 261. Generator Authorized Agent Name(Print) . Signature r. Date II. TRANSPORTER Generator completes Ila-b and Transporter completes Ilc-e a.Transporter's Name and Address: b.Phone: c.Driver Name Print d. Signature e.Date III. DESTINATION (Generator complete Illa-c and Destination Site completes Illd-g) a.Disposal Facility and Site Address: c.US EPA Number d.Discrepancy Indication Space: b. I hereby certify that the above named material has been accepted and to the best of mX knowledge the foreqoinp is true and accurate. e.Name of Authorized Agent Print f.Signature I a.Date IV. ASBESTOS (Generator completes IVa-f and Operator complete IVg-i) a.Operator's Name and Address: c.Responsible Agency Name and Address: b. Phone: d.Phone: e.Special Handling Instructions and Additional Information: f.❑ Friable ❑ Non-Friable ❑ Both %Friable %Non-Friable OPERATOR'S CERTIFICATION:I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name and are classified,packaged,marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable intemational and national governmental regulations. 9.O erator's Name and Title Print h.Signature I.Date *Operator refers to the company which owns,leases,operates,controls,or supervises the facility being demolished or renovated,or the demolition or renovation operation or both REV 01/14 GENERATOR RETAIN RS-F11A