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liBL IC' <br />ICES <br />t-A-Xk <br />DATE <br />TIME <br />R=ft <br />00 REPUBLIC dolt SERVICES <br />784 <br />GENERATOR (Gene <br />DRIVER Vkt <br />TRUCK NO. S 363 <br />CUSTOMER <br />17 /3 m <br />ADDRESS <br />Acct, No. Total Ton • <br />QUANTITY <br />_ <br />4---- ,,,,Tior .....(2,, BIN PICKED UP . <br />I\ I ra. sk <br />) <br />0 GOOD 0 FAIR <br />0 POOR <br />BIN DELIVERED <br />00000 0 FAIR <br />0 POOR <br />DELIVERED TO: 0 BIS orward 0 R&R 0 SR 0 Lovelace 0 Harney Lane 0 Yard 0 Other <br />10 cubic yard bins maximum 5 TONS: Dirt, Concrete, Gravel and Asphalt are accepted <br />20 cubic yard bins maximum 3 TONS: Trash and All types of roofing - No Dirt/Concrete <br />40 cubic yard bins maximum 4 TONS: Trash and Woodshake roofing only - No DirU Concrete <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 />GENERATORS CERTIFICATION: <br />state law, has been properly describ <br />waste is a treatment residue of a pre <br />been treated in accordance with the <br />TRANSPORTER (G <br />a. Transporters Name and Address <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 />I have read and understand Republic Services Policy: Signed <br />NS-039 (12/14) <br />p. Generator Authorized Agent Nam <br />b. Phone: <br />e Date d Signature e Driver Name (Print) <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 Authorized Agent (Print) _f. Signature A. Date <br />ESTOS Generator completes (Va-f and Operator complete IVg-i) <br />Operator's Name and Address: <br />Phone: <br />Responsible Agency Name and Address: <br />Phone: <br />Special Handling Instructions and Additional Information: <br />0 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 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 />ci. Operator's Name and Title (Print) h. Signature _ i. Dale <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 />el <br />• <br />• <br />• <br />RS-F11A GENERATOR RETAIN REV 04119 <br />a. Generators US EPA ID Number <br />d. Generator's Name and Location <br />f. Phone <br />If owner of the generating facility cliff <br />h. Owners Name: <br />j Waste Profile # <br />CO <br />CTI <br />CD <br />0) <br />NOT RESPONSIBLE