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e Date ! d. Signet:ire C. Driver-Name (Print) <br />1 g. Date e. Name of Authorized Agent (Print) 1 f Signature <br />TRANSPORTER (Generator completes 118-b anti Transporter completes Ilc-e) <br />a Transporter's Name and Address: <br />b. Phone: <br />1 <br />DESTINATION (Generator complete lila-c and Destination Site completes Illd-g) <br />a Disposal Facilrty and Site Address' c US EPA Number 1 if. Discrepancy Indication Space <br />I hereby certify that the above named material lies been accepted and to the best of my knowiedoe the foramina is true and accurate <br />Cki r'r REPUBLIC <br />4194 SERVICES <br />NON-HAZARDOUS SPECIAL WASTE & ASBESTOS MANIFEST <br />If waste is asbestos waste, complete Sections 1, 11,111and IV <br />If waste is NOT asbestos waste, complete Sections III and III <br />I. GENERATOR (Generator completes la-r) <br />a Generators US EPA ID Number P. Manifest Document Number <br />.. . <br />c. Page 1 of <br />cl. Generator's Name and Location: <br />I. Phone.--, . I . s. :: 7.. <br />e. Generator's Mailing Address: <br />g. Phone: <br />If owner of the generating facility differs from the generator. provide. <br />h. Owner's Name: i. Owner's Phone No.. <br />f. Waste Profile # k. Exp Date L Waste Shipping Name and <br />Description <br />m Con =ere <br />Type <br />n. Total <br />Quantity <br />o. Unit <br />WtNot No. <br />_ — _ <br />GENERATOR'S CERTIFICATION: I hereby certify that the above named material is not a riazaraous waste as defined by 40 CFR 261 or any applicable <br />state law, has been properly described. classified and packaged, and is in proper cond.tion for transportation according to applicable regulations: AND, if this <br />waste is a treatment residue of a previously restricted hazardous waste subfect to ihe 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 />_ ---",z7 7r---4------.. <br />p. Generator Authorized Agent Nerrie (Print) -' i a. Signature- r Date <br />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: if, Phone: <br />e. Speaat Handling Ir.structions and Additional Information- <br />!. 0 Friable 0 Non-Friable 0 Both *.t Friable % Non-Friable <br />OPERATOR'S CERTIFICATION: I tereby declare tha: 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 />1 <br />g. Operators Name arid Tile (Printi t r, Sionature i. Date <br />'Operator refers to the company which owns, leases, operates, controls, or sJpervises the ready being demolished or renovated, or the demolition or <br />renovation operation or both <br />rzEv 0104 TO C.,E.-:NERF.TCF: <br />RS-Fl IA <br />-