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FREPUBLIC NON -HAZARDOUS SPECIAL WASTE & ASBESTOS MANIFEST sf=t3vfces If waste is asbestos waste, complete Sections I, Il, 111 and IV If waste is NOT asbestos waste, complete Sections 1, 11 and III I. GENERATOR (Generator completes la -r) a. Generator's US EPA ID Number and Trartsrarter corn b. Manifest Document Number c. Page 1 of d. Discrepancy Indication Space: d. Generator's Name and Location: e. Generator's Mailing Address: - b. Phone: t d. Phone: _ f. Phone: .. g. Phone: e, Special Handling Instructions and Additional Information: I hereb '. certify that the If owner of the generating facility differs from the generator, provide: above named material has been ac ' ted and to the best of my h. Owner's Name: 1. Owner's Phone No,: - ❑ Friable 0 Non -Friable D Both % Friable j. Waste Profile # k. Exp. Date 1. Waste Shipping Name and m. Containers OPERATOR'S CERTIFICATION: I hereby n. Total of this consignment are fully and accurately described above by the proper shipping name o. Unit No. for transport according to applicable international and Type i! f. it Description Quantity Wt/Vol O e rati 1 's Name anU Title nt) _.. 2 '�e, Name of Authorized Agent Print i. f. Si nature' `-%' I 'Operator refers to the company which owns, leases, operates, cq ftls, or supervises the facility being Date - renovation operation or both 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. t certify and warrant that the waste has been treated in accordance with the requirements of 40 GFR 268 and Is no longer a hazardous waste as deft ed by 40 CFR 261_ Generator Authorized Agent Name (Print) q. Signature r. Date a. Transporter's Name and Address: b_ Phone: _ Z6 Z�5 c. Driver Name (Print) v_ 'd. Si nature _.' e. Date ilia DESTINATION (Generator complete Ilia -c 4 Destination Site completes 111d -g) a. Disposal Facility and Site Address: c. US EPA Number d. Discrepancy Indication Space: - b. Phone: t d. Phone: b. e, Special Handling Instructions and Additional Information: I hereb '. certify that the above named material has been ac ' ted and to the best of my knowled a the for of iS true and accurate.: f. ❑ Friable 0 Non -Friable D 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 r for transport according to applicable international and national governmental regulations. i! f. it Le L O e rati 1 's Name anU Title nt) A. Si na '�e, Name of Authorized Agent Print i. f. Si nature' `-%' I 'Operator refers to the company which owns, leases, operates, cq ftls, or supervises the facility being Date - IV. ASBESTOS .(Generator completes IVa -f and Operator complete IVg-i) a. Operator's Name and Address: REV 01114 c. Responsible Agency (Jame and Address - b. Phone: d. Phone: e, Special Handling Instructions and Additional Information: f. ❑ Friable 0 Non -Friable D 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 international and national governmental regulations. Le L O e rati 1 's Name anU Title nt) A. Si na i. Date 'Operator refers to the company which owns, leases, operates, cq ftls, or supervises the facility being demolished or renovated, or the demolition ar renovation operation or both RS•F11A