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REV 04 /1 9 <br />DESTINATION RETURN <br />f. Friable 0 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 <br />by the proper shipping name <br />and are classified, <br />packaged, marked and tabeled/placarded, and are in all respects in proper condition for transport according to applicable international and national governmental regulations. <br />i ' Date Operator refers to <br />the company which owns leases, operates, controls, or supervises the facility being demolished or renovated, or the demolition or <br />. <br />I'. S ature <br />renovation operation or both <br />RS-F It <br />CD <br />0 —h <br />4 SH 'woiaes eu!Tsp>i REPUBLIC NON-HAZARDOUS SPECIAL WASTE & ASBESTOS MANIFEST <br />I H <br />t-11141 <br />SERVICES <br />a <br />1400622 <br />a <br />if waste is asbestos waste, complete Sections I, II, Ill and IV <br />It waste is NOT asbestos waste, complete Sections I. II and III <br />c. Page 1 of <br />e. Generators Melling <br />P e-- rviowsi •Ce <br />I70 not -4,4o "tn. R--....^%LtSco COI <br />5. Phone: <br />I. Owners Phone Na.; <br />j. Waste Profile # k. Exp. Dale I_ Waste Shipping Name and <br />Description <br />m. Containers n Total <br />Quantity <br />o. Unit <br />WVVol No. Type <br />*2.0 171- Yq I / I 7g <br />Noi Aim -2-qw-devs <br />‹.-0 e- I di in 1 C ill <br />GENERATORS <br />been treated in accordance with the requirements of 40 CFR 268 and is no lo r a hazardous waste as defined by 40 CFR 261. <br />stale 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 subject to the Land Disposal Restrictions. I certify and warrant that the waste has <br />/A/ re— Mc- <br />r. Date <br />d. Generator's Name an Location' Ph G"-- Roime—r. 12.4 <br />C.4 os-203 al I I Phone: <br />GENERATOR (Generator completes la-r) <br />I , a. Generators US EPA yumber <br />hi 4 <br />i b. Manifest Document Number <br />If owner of the generating facility differs from the generator. provide: <br />ents-e. <br />Generator Authorized A ent Name (Print) <br />TRANSPORTER Generator com letes Ila-b and Trans <br />Transporter's Name and Address: <br />PcC, losjvart:t, 0 4-5-0VeCli,;1 4-- 2.45-0tIJ , Fr-eryt try t-:01 q‘ZO 3 Phone: P/771 324 - /6 <br />q Signature <br />4 <br />) 1 <br />4 <br />oiler com letes Ilc-e <br />/7 g. zaci — eiztO 2- - J-2 3tr7 <br />ef7-1-Y73 <br />d Phone: <br />b. Phone: <br />e. Special Handling Instructions and Additional Information: <br />IV. ASBESTOS (Generator completes IVa-f and Operator complete IVg-i) a. Operator's Name and Address: <br />e. Name of Authorized Agent (Print) f. Signature [g. Date <br />Could _17 <br />9991 s. Rd- <br />b. q5-33A <br />I hereby certify that the above named material has been accepted and to the best of my knowledge the foregoing is true and accurate. <br />C. Driver Name (Print) d. Signature e. Date III. DESTINATION (Generator complete (((a-c and Destination Site completes Illd-g) <br />a. Disposal Facility and Sitrddress: c. US EPA Number d. Discrepancy Indication Space: <br />Responsible Agency Name and Address: <br />/ - I 64-24 <br />) <br />HI 1 <br />)