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REPUBLIC NOWHAZARDOUS SPECIAL WASTE & ASBESTOS MANIFEST
<br />SERVICES
<br />23 8 If waste is asbestos waste, complete Sections I, 11, III and IV
<br />14
<br />r.. -•-, (� If waste is NOT asbestos waste, complete Sections i, II and 11I
<br />t_ (;FNP=RATC)k (Generator completes la -r)
<br />a. Generator's TEPA ID Number
<br />TRANSPORTER
<br />b. Manifest Document Number
<br />c. Page 1 0l
<br />N A
<br />fCrRL;attUtt,fiEttt ltd +_.,
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<br />d. Generator's game and Location:
<br />e. Generator's Mailing Address:
<br />poliq Ott'at+Jtiiiur4 Cl Ai};tOrnsrktIna
<br />F"<'r B (,ix 1089
<br />y't3trti�t.=a�'d3:sftlil)too=+t.+Ir'�JEFak�5�1i
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<br />aCwAitf.origCA`5 01
<br />ti,.4'SCti. �{iTt..3� histtiezin.+:t= t5.a:.�ii�;-�J..t,?tt
<br />,
<br />b, r
<br />I '
<br />f. Phone:
<br />g. Phone:
<br />ece'ted and to theibest of my
<br />knowledge the foregoing is t6je and
<br />a)cc rate: -
<br />If owner of the generating facility differs from the generator,
<br />provide:
<br />j
<br />h. Owner's Name: •,•, , iyf
<br />i. Owner's Phone Nadn,;r-•g49.17 7.,;9
<br />j. Waste Profile #
<br />k. Exp. Date
<br />natdre'
<br />I. Waste Shipping Name and
<br />m. Containers
<br />n. Total
<br />o. Unit
<br />No.
<br />pe
<br />Description
<br />Quantity
<br />WWoi
<br />Qrtriber 77, 2016
<br />Nor, Ni-dible
<br />�
<br />AT
<br />GA
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<br />GENERATOR'S CERTIFICATION: I hereby certify that the
<br />above named material is not. a hazardous waste as defined by 40 CFR 2.61 or any
<br />applicable
<br />state law, has been properly described, classified and packaged,
<br />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
<br />waste has
<br />been treated in accordance with the requirements of 40 CFR
<br />266 and is no longer a hazardous waste Es defined by 40 CFR 261.
<br />.
<br />? .r
<br />_ .-f�! _. ,.
<br />—
<br />/: r
<br />p. Generator Authorized Agent Name (Print)
<br />_
<br />q.
<br />Signature
<br />r. Date
<br />(Generator con .Metes fla-b and Tra
<br />a. Transporter's Name and Address: _
<br />T_ i4tggVj"efI el it. 1110-..
<br />€It Offi , lt,i`, 14pF I
<br />b. Phone:
<br />c. Driver Name (Print) I d. Signature
<br />In_ nESTINATIC]t+i fGenerator comolefe ►Ila -c and Destination Site completes Illd-q)
<br />a. Disposal Facility and Site Address: c. US EPA Number d. Discrepancy Indication Spec
<br />IV, ASB
<br />,%
<br />e•
<br />fCrRL;attUtt,fiEttt ltd +_.,
<br />f
<br />-4 :C,Ln3'itT f siPA,�
<br />�
<br />,
<br />b, r
<br />I '
<br />I VerebV certify that{lhe. above named material has taken
<br />ece'ted and to theibest of my
<br />knowledge the foregoing is t6je and
<br />a)cc rate: -
<br />j
<br />e'Name`of Autho#0 A ent Print f.
<br />natdre'
<br />9• pa a
<br />STOS {Generator completes lVa-f and Operator complete IVg-i
<br />a. Operators Name and Address: � c. Responsible Agency Name and Address
<br />Fcrr of 7011r6;ac: I=re Fta
<br />x
<br />aL�i ft tai;1rl1W*U" a:�'it 3OcWsin;%st v2Cti
<br />5C"v.:h�t1lF, %/: Ca.S71ix ���:-5a+•+-�r:,sr
<br />b. Phone:,. c... .rl, , d. Phone:
<br />e. Special Handting Instructions and Additional information:
<br />'Gt]ni}L bra liY 173L'S.R .rq.iit%S+;:urlir;isYisl }5 T. Aa�t .n4er+Y,i LDrfiCa2 vY y» ,h3�i1uSW,ti.ra T�s?�--:., 2'4�1':7.g-ittl .�. I f�,t.JOB t'�IE�MUI R �rj-';7 Crit
<br />OPERATOR'CERTIFICATION: I hereby declare that the contents of
<br />S this consignment are fully and accurately described above by the proper shipping nam
<br />and are classified, packaged, marked and labeled/placarded, and are in all respects in proper condition for transport according to applicable intern
<br />ational and
<br />national governmental regulations.
<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
<br />operation or both t- •
<br />REV 01114 GENERATOR RETAIN RS-F11A
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