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REPUBLIC` NON-HAZARDOUS SPECIAL WASTE & ASBESTOS MANIFEST <br /> SERVICES <br /> If waste is asbestos waste,complete Sections I,Il, III and IV <br /> �)M12111 If waste is NOT asbestos waste,complete Sections I, II and III <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; tc, 's Mailing Address: <br /> (7c i <br /> f. Phone: 1 V 1`!��, i \l r� �� (� I l L <br /> c,�Pho�e:Y r1Ltn f%�.n�� �( n /1� � � �r (1 <br /> If owner of the generating facility differs from.'the generator, provide: <br /> h.Owner's Name: ���" ! tj ` �? i. Owner's Phone No. <br /> j.Waste Profile# k.Exp.Date I.Waste Shipping Name and m.Container,, n.Total o. Unit <br /> Description No. Type Quantity WWol <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. Si nature r.Date <br /> II. TRANSPORTER Generator completes Ila-b and Transporter completes Ilc-e <br /> a;Transporter's Name and Address: 7j r�,l - 0 . \01 C <br /> icivo U, 'b.Phone: �n A. <br /> c'- rof, <br /> ..,. n,�rif ,P 1 n "n� �� it,� <br /> c.Driver Name(Print �d. Si nature e.Date <br /> Ill. 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 /> L�L�GlJJ c('tom{�-� I•l.t `� � f�j 1, / I <br /> b. <br /> I hereby certify that the above named material has been accepted and to the best of my knowledge the foregoing is true and accurate. <br /> e.Name of Authonzed Agent Print f. Si nature q. 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❑ Friable ❑ Non-Friable ❑ Both %Friable o 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 classified,packaged,marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable international and <br /> national governmental regulations. <br /> g.Operator's Name and Title(Print) In. Signature i. Date <br /> "Operator refers to the company which owns,leases,operates,controls,or supervises the facility being demolished or renovated,or the demolition or <br /> renovation operation or both <br /> RETURN TO GENERATOR <br /> REV 01/14 RS-F11A <br />