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If waste is asbestos waste, complete Sections I, lP III and IV
<br />if waste la NOT asbestos waste. complete Sections I 11 and III
<br />• st_Rupt
<br />wog rv REPUBLIC' NON-HAZARDOUS SPECIAL WASTE & ASBESTOS MANIFEST +.4 SERVICES
<br />6300923
<br />IL 'TRANSPORTER (Generator completes Ila-b and Transporter completes Ilc-e)
<br />4,1 /7/ 7
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<br />Driver Name (Print) d. Signature e. Date
<br />IV. ASBESTOS Generator completes IVa-f and Operator 'Ciro-motets IVg-l)
<br />RETURN TO OPERATOR RS-F11A REV 01/14
<br />1..
<br />i a. Generator's US EPA ID Number b. Manifest Document Number
<br />r- 5 7 _,- -;-. -
<br />c. Page 1 of
<br />i
<br />Generator's Name and Location:
<br />PaCiFTC. 7-3.f.c4 r.% ELE 7P1( C D ;
<br />PO Pi* 7F-1-4) "2 0"
<br />' t phom c:A''lPaN."-,'..1'.•:' Cr, C-A , 141 Xl - 1.-' '2.
<br />B.-Generator's Mailing Address:
<br />t'..1-Ii--',C .7:•,/tz, 1, E, FIR; (
<br />CV 1 MI t: FAS T r_u: Acit_74Rf)%5
<br />g. Phone.' (n) +7.11 e624D
<br />If owner of the generating facility differs from the generator, provide:
<br />h. Owner's Name: I. Owner's Phone No.:
<br />J. Waste Profile # k Exp. Date I. Waste Shipping Name and
<br />Description
<br />m. Containers n. Total
<br />Quantity
<br />o. Unit
<br />WINol No. Type
<br />eg-i111)11i i;.1. 1)19C2t1 RiTi';': eckZARFJC), IS SCE_ CYO gA c-> 7 / ( `r
<br />lei)
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<br />GENERATORS CERT1FiCATI0N: !hereby certify that the above named material is not a hazardous waste as defined by 40 CFR 281 or any applicable
<br />state law, has bean 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 end 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 281.
<br />7 •.-/
<br />./e ••'. .. 1 •- , -- -
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<br />
<br />__,..---'"-- ' --, - " • -
<br />p. Generator Authorized Agent Name -Tara) q, Signature-- r. Date
<br />a. TTEITI5PP:r.`:;,i91,14PcY.,fr5;01.2RCIW,
<br />'2i7VI 1711r::.t-SNT
<br />S111;;ATC",\4. t a5)
<br />b. Phone:
<br />DESTINATION (Generator complete lila-c and Destination Site completes Illd-q)
<br />
<br />. .
<br />a. Disposal Facility and Site Address:
<br />RDP W.A9D WrAt_t
<br />
<br />1/: %109 3/4 fig,,i Ai ..z..717.4 P1c,11) 7—
<br />
<br />Fr'A f7,;0273:--.C.6 p0 ,0 N1 .a20
<br />c. US EPA Number
<br />!ii,
<br />ti. Discrepancy Indication Space:
<br />1 1
<br />Iiitareby certify-that the above named material has been accepted and to the best of my knOwiedtre the fcreotriqiitrue and geometer- i I
<br />(.„..:1-7,../.4.: : ., \
<br />(i 1. \ /-----__ / , , 1 -\-
<br />..19:11,4M8 ofAtithorized Agent (Print) ‘‘.....Slerfattfre l ii g. Date
<br />sa. Oparatie3sine end Address: a - ....... L
<br />,. .4,/ -,-_,.. 1e , ..
<br />c. Responsible Agency Name and Address:
<br />d. Phone:
<br />,,,Ar ' .A.. ....,A 2( •
<br />1-1--. --7-4-:, -..........,4s_
<br />,..: ,. _
<br />b. [Irene: -.,-/ 'r .-
<br />e. Special Handling Instructions and Additional Information:
<br />1. Cl Friable 0 Non-Friable 0 Both % Friable % Non-Friable
<br />OPERATORS CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,
<br />end are classified, packaged, marked and labeled/placarded, and are in aft respects in proper condition for transport according to applicable International and '
<br />national governmental reguIations.
<br />--, . — ., • .. — ,
<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 nanavated, or the demolition or
<br />renovation operation or both
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