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7._-,:z.c..,,_,,...,.....,....,......_ <br />R.p, Ck. r. REPUBL <br />tW SERVICES ORM <br />I () i 0 DRIVER <br /> <br />, Ckr Tn REPUBLIC —1- 11 -1- 2.0 <br />idei SERVICES DATE <br />TRUCK NO TIME `..li (14-1M/PM <br />CUSTOMER <br />ADDRESS <br />Acct No Total Tons' <br />QUANTITY TY ESCRI ON _--- <br />BIN PICKED UP <br />a <br />1 1 -I-De I , 'N T.e 0 GOOD 0 FAIR <br />0 POOR <br />BIN DELIVERED <br />06000 O FAIR <br />0 POOR <br />_0 <br />I. GENERATOR (G <br />a Generators US EPA ID Numb <br />d. Generators Name and Locatio <br />f. Phone: <br />If owner of the generating facility <br />h Owners Name <br />I Waste Profile # <br />DELIVERED TO: Cl ESTS 'VI-Forward 0 R&R 0 SR 0 Lovelace 0 Harney Lane 0 Yard 0 Other <br />10 cubic yard bins maximum 5 TONS: <br />20 cubic yard bins maximum 3 TONS: <br />40 cubic yard bins maximum 4 TONS: <br />Dirt, Concrete, Gravel and Asphalt are accepted <br />Trash and All types of roofing - No Dirt/Concrete <br />Trash and Woodshake roofing only - No Dirt/ Concrete <br />411, <br />Additional charges may apply if bins exceed the maximum weight limit. All bins with waste above the rim <br />will be charged additional daily charges until bin is leveled and removed. <br />UPON CUSTOMER REQUEST FOR BIN PLACEMENT, REPUBLIC SERVICES IS <br />FOR ANY DAMAGE TO DRIVEWAY AND/OR PROPERTY. <br />NOT RESPONSIBLE <br />GENERATOR'S CERTIFICATIO <br />state law, has been properly des( <br />waste is a treatment residue of a <br />been treated in accordance with <br />Republic Services DOES NOT accept the following waste types: <br />LIQUID - PAINTS - OIL - TIRES - GREASE - PESTICIDES - SOLVENTS - CHEMICALS - FREEZERS <br />ICE MAKERS - REFRIGERATORS - AIR CONDITIONERS - TOXIC, RADIOACTIVE, EXPLOSIVE, HIGHLY <br />VOLATILE, FLAMMABLE, or HAZARDOUS MATERIALS. <br />I CERTIFY THAT NONE OF THE ABOVE WASTE TYPES ARE CONTAINED IN THIS LOAD. <br />p. Generator Authorized Agent N <br />U. TRANSPORTER <br />a Transporter's Name and Addr <br />I have read and understand Republic Services Policy: Signed <br />NS-039 (121141 <br />b Phone <br />e Date c Driver Name (Print d Signature <br />• <br />DESTINATION (Generator complete lila-c and Destination Site completes Illd-g) <br />a Disposal Facility and Site Address <br />b <br />c US EPA Number d Discrepancy Indication Space <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 />e. Name of Authonzed Agent (Print) f. Signature g. Date <br />IV. ASBESTOS (Generator completes IVa-f and Operator complete IVg-i) <br />Operator's Name and Address' <br />Phone: <br />c Responsible Agency Name and Address: <br />d. Phone: <br />Special Handling Instructions and Additional Information: <br />LI Friable 0 Non-Friable 0 Both 'Xi 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 intemational and <br />national governmental regulations. <br />q. Operator's Name and Title (Print) Is. 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 operation or both <br />REV 04119 GENERATOR RETAIN RS-F11A <br />• <br />410 <br />• <br />• <br />• <br />•