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• • • • • • a. Generator's US EPA ID Number b Manifest Document Number c. Page 1 of d. Generator's Name arid Location f. Phone: e Generator's fitaifing Address g Phone. If ormer of the generating facy differs from the generator. provide- h. Owner's Name. i Ormer's Phone No.: j. Waste PTcf9e # IL Exp. Date I. Waste Shipping Name and Description nt Containers n_ Total Quantity o. UM viWi/ol No. I Type t. - GENERATOR'S CERTIFICATION: I hereby certify that the above named material stale law, has been properly deserted. classified and packaged. and is in proper waste is a treatment residue of a previously restricted hazardous waste subject been treated in accordance with the regui-ements of 40 CFR 268 and is no longer is not a hazardous waste as defined by 40 CFR 261 or any appicable amazing to applicable regulations AND. i Mb I certiy aid warrant that the waste tars by 40 CFR 261. condition for transportation to the Land Deposal Rests. a hazardous waste as defined p. Generator Authorized Agent Name (Pant) I q. Signature c Date I. GENERATOR (Generator completes la-r 83. 32 REPUBLIC SERVICES NON-HAZARDOUS SPECIAL WASTE & ASBESTOS MANIFEST If waste is asbestos waste. complete Swims I. II. III arid IV If waste is NOT asbestos waste. complete Sedims I. II and III • • • • • lj • • • Disposal Fact'hy and See Address: a US EPA Number ... d. Discrepancy Indication Space: I hereby certify that the above named material has been accepted and to the best of my knowledge the trasiistelitle arid aCCINale. e. Name of Authorized Agent (Print) f. Signature • • • • Operator's Name and Address: Phone: d Responsible Agency Name and Address d. Phone: a Special Handling Instructions and Additional Information: 1.13 Friable =2 Non-Friable 0 Both % Friable % Non-Friable OPERATORS CERTIFICATION: I hereby declare that the contents of this consignment are fuly and accurately descrbed above by the proper stipping name and are classified. packaged. marked and labeled/placarded, and are in at respects in proper condition for transport acconing to amicable International end rational governmental regulations. 1 . ci. Operator's Name and Title (Print) h. Signature i Date 'Operator refers to the company vrhich owns, leases, operates, controls, or supervises the facility being demolished or renovated, or the dernottron or renovation operation or both N. ASBESTOS (Generator completes tVa-f and Operator complete IV • • • • REV 04119 GENERATOR RETAIN RS-Ft s • TRANSPORTER (Generator completes Ha-b and Transporter completes 11c-e) a Transporters liar.ne and rirlikess. i 45 iAf. Cf.ants Weer - 052`1". b. Phone. • Driver hlame (Print) a. Date DESTINATION (Generator complete lila-c and Destination Site completes I d Signature