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REPUBLIC NON-HAZARDOUS SPECIAL WASTE &ASBESTOS MANIFEST <br /> SERVICES <br /> If-was(e is asbestos waste,complete Sections I,II,III and IV <br /> If waste is NOT asbestos waste,complete Sections 1,11 and III <br /> I. GENERATOR (Generator Completes la-r) <br /> a.Generators US EPA 10 Number I b.Manifest Document Number c Page 1 of <br /> i <br /> d.Generators Name and Location: - It.Generator's Mating A.-dress <br /> f Phone: g.Phone: <br /> It owner of the generating facility diners from me generator,provide. <br /> h Owner's Name: i.Owner's Phone No: <br /> j.Waste Profile# k.Exp.Date I.Waste Shipping Name andm uuv n.Total o Unit <br /> Description No. Toe Quantity WtNol <br /> I <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 1 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 b 40 CFR 261. <br /> :Generator Xiilf ted Agent Name(PiR q,Signatre r.Oatei <br /> U. TRANSPORTER (Generator completes Ila-b and Transporter completes lio-e <br /> .TTanscor,-,'s frame and Address: <br /> b. <br /> c-Driver Name(Pnntl Sbeature I e Date <br /> III. DESTINATION (Generator complete Illa-c and Destination Site completes 111d-g) <br /> a.Ofsoosal Facility and Site Address c US EPA Numoer d.Discrepancy Indication Space. <br /> b' <br /> hereby cerbf that the apove maned material has been tee and to the best of my knowfedoe me fcfeg"g:s true and accurate <br /> "ame of Authorized ent IPnrU I; _ Date _ <br /> IV. ASBESTOS (Generator compte'.es IVa-f and Operator Complete[Vg-i) <br /> s OpmaWl's iVarne and r+tldreas, c Responsible Agency Name and Address: <br /> b Phone- <br /> d.Phone: <br /> e.Special handling Instructions and Additional Information. <br /> t.C1 Friable D Non•Fnable -7 Both <Friable %Non-Friable <br /> OPERATOR'S CERTIFICATION:1 hereby declare that the contents of this consignnteni are fulty and accurately described above by the proper shipping namel <br /> arM are fed,packaged,marked and labelediplacarded,and are in all respects in proper condition for transport according to applicable intemational and <br /> naaonal govemmeitl8l regulations <br /> a.Operators Name and T'Ne Mrint; Ih. <br /> St nature i.Date <br /> 'Operator refers,.o the company which owns,leases,operates,controls.or superASes the facility being demolished or renovated.or the demolition or <br /> renovation operation or both <br /> REVCv 14 GENERA'OR <br /> RS-f i t A <br />