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IV. ASBESTOS (Generator completes IVa-f and Operator complete IVg-i) <br />REV 04 /19 GENERATOR RETAIN RS-Fi IA <br />Rum 4kr 00 REPUBLI <br />606 SERVICES <br />785151 DRIVER \ <br />TRUCK NO. <br />CUSTOMER <br />ADDRESS <br />GENERATOR (Gel <br />a. Generator's US EPA ID Number <br />IRV <br />BLIC <br />SERVICES DATE <br />rIME AM/PM <br />d. Generator's Name and Location <br />f. Phone: <br />If owner of the generating facility di <br />h. Owner's Name. <br />Waste Profile # <br />GENERATOR'S CERTIFICATION <br />state law has been properly desert <br />waste is a treatment residue of a p <br />been treated in accordance with th <br />p. Generator Authorized Agent Na <br />TRANSPORTER ( <br />a Transporters Name and Address. <br />Total Tons: <br />QUANTITY <br />BIN PICKED UP <br />.___i_70E1.5,CR(IRTICisti\ <br />0 GOOD 0 FAIR <br />0 POOR <br />BIN DELIVERED <br />0 GOOD 0 FAIR <br />0 POOR <br />DELIVERED TO: 0 ESTS 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 />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 NOT RESPONSIBLE <br />FOR ANY DAMAGE TO DRIVEWAY AND/OR PROPERTY. <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-03 <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 />• <br />b Phone • <br />c Driver Name (Print) d Signature e. Date <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 for oing is true and accurate <br />e. Name of Authorized Agent (Print) f. Signature g. Date <br />Operator's Name and Address: <br />Phone: _I <br />c Responsible Agency Name and Address: <br />d. 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 deschbed 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 />Operator's Name and Title (Print) Signature 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 />• <br />• <br />• <br />• <br />• <br />• <br />10} <br />• <br />• <br />• <br />• <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 CONDMONERS - TOXIC, RADIOACTIVE, EXPLOSIVE, HIGHLY <br />VOLATILE, FLAMMABLE, or HAZARDOUS MATERIALS.