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187) REPUBLIC NON -HAZARDOUS SPECIAL WASTE & ASBESTOS MANIFEST SERVICES 8 �? 4 6 0 If waste is asbestos waste, complete Sections I, II, III and IV If waste is NOT asbestos waste, complete Sections I, II and III 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: l:acirxy l; titsovk: fy.YK! ti �uatln Road r 8476 E Kettlemen f. Phone: 1 --,r ^.A f6240 g, Phone: 1l If owner of the generating facility differs from the generator, provide: h. Owner's Name: I i. Owner's Phone No.: j. Waste Profile # k. Exp. Date I. Waste Shipping Name and m. Containers n. Total o. Unit Wt[Vol Description No. T e Quantity i tT 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 266 and is no longer a hazardous waste as defined by 40 CFR 261. p. Generator Adthodzed Agent Name Print . Signature 11. IKANbPUK I CK generator cum ICItlJ rra ar ru r i ai is Vr wi r Wl I 1 a. Transporter's Name and Address: 1 F , 1T4n b. Phone: 71 c. Driver Name Print d. i nature e. Date a. Disposal Facility and Site Address: c, US EPA Number d. Discrepancy Indication Space: . .1:--„ LdAhll 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 fy.YK! ti �uatln Road r national govemmental regulations. b. -i , renovalion operation or both I hereb cern that the bove named material has been a ce ted and to the best of m knowled a the for oln is true and accurate. e. Name of Authorized Agent Print f. Signature Date rte. ...... �-...... .... .....-. __. .r-__- -- 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 international and national govemmental regulations. O erator's Name and Title Print h, Si nature i. Dat e 'Operator refers to the company which owns, leases, operates, controls, or supervises the facility being demolished or renovated, or the demolition or renovalion operation or both RS -1`11A REV 01!14 RETURN TO GENERATOR