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e. Date Driver Name (Print)
<br />TRANSPORTER (Generator completes Ha-b and Transporter completes Ilc-e)
<br />Transporter's Name and Address. ' v.)/ 00 /1
<br />P5C. iv -s% f I-- 5- 0 v eci ri
<br />2_03-0 frVtte%Ir • '5176K--h...\ Lar
<br />Phone: 006 3).4 • id3a
<br />/1•1- v.1.1
<br />d. Signature
<br />41. too REPUBLIC
<br />iikto SERVICES
<br />NON-HAZARDOUS SPECIAL WASTE & ASBESTOS MANIFEST
<br />; If waste is asbestos waste, complete Sections I. II. III and IV
<br />If waste is NOT asbestos waste, complete Sections, II and Ill
<br />GENERATOR (Generator completes la-r) /11-7 o.-32-P )
<br />a. 3enerator's US EPA ID)Number
<br />1 ' N 4, b. Manifest Document Number c. Page 1 of
<br />ti Oeneratoes Name and Location.
<br />'';,' 2.?ti ic-4‘,ober-l-c &LI. Fl h :-
<br />`.1-64. k4-4., C.421 4;13-2. 03
<br />I. Phone.. kV11 g 2l--L .3
<br />H. Generator's Mailing Addrv - -
<br />ro RI./ Ii40 C., , (7,-_ , , 6
<br />If owner of the generating facility differs from the generator, provide:
<br />,
<br />h. Owner's Name: i. Owner's Phone No.:
<br />j. Waste Profile it k. Exp. Date I. Waste Shipping Name and
<br />Description
<br />m. Containers n. Total
<br />Quantity
<br />o. Unit
<br />Wt/Vol No Typo
<br />'
<br />—; f- f---1 -2 () a • "C) r i 1 - , 1 . 1 .. , ' ,
<br />. . -1 i - N , ..,,-•i.,,, .4.( .
<br />:,..---.; . Y
<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 sublect to the Land Disposal Restrictions I certify and warrant that the waste has
<br />been treated In accordance with the requirements of 40 CFR 268 d is no lopger a hazardous waste as defined by 40 CFR 261.
<br />''.i , C 01 viC...11 e a-
<br />0A1 tes•A- ' —"- rid-7'
<br />ii.Y1,4,:i -t:_A.,,,ya __,J
<br />t . ,
<br />p Generator Authorized Agent Name (Print) q. Signature r. Date
<br />DESTINATION (Generator complete lila-c and Destination Site completes Illd-g)
<br />Fr. Dispoiial Facilily .r.ii id F3IttAdi.lresii. recole e.,,j, 4: ..m..., d 4---al
<br />4.;4994,i 5 At ..,•:.J, .. R.,,,41
<br />b. riefir;1 IA .1 ec,„. Cr
<br />c. US EPA Number
<br />•
<br />d Discrepancy Intik:Wiwi Space,
<br />I hereby certify that the above narwd material has been accepted and to the bestiof my 4knowledgo the foregoing is true and accurate
<br />\ 1 , 1 i . , _ I
<br />t
<br />1. P i 1 I ; I i
<br />e. Name of Authorized Agent (Print) f. ', 'nature • ' 9. Date
<br />IV. ASBESTOS (Generator completes IVa-f and Operator complete IVg-i)
<br />a Operator's Name and Address.'
<br />b, Phone:
<br />Responsible Agency Name and Address:
<br />Phone:
<br />Special Handling Instructions and Additional Information: _.
<br />1.0 Friable (3 Non-Friable 0 Both % Friable % Non-Friable
<br />OPERATOR'S CERTIFICATION: I hereby declare that 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 />g. Operator's Name and Title (Print) h. Signature i. Date
<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 °aeration or both
<br />RERIRN To OPERATOR RS-F11A REV 04 /1 9
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