Laserfiche WebLink
I. <br />00 REPUBLIC NON-HAZARDOUS SPECIAL WASTE & ASBESTOS MANIFEST <br />SERVICES <br />If waste is asbestos waste, complete Sections III, Ill and IV <br />If waste is NOT asbestos waste, complete Sections I, II and III <br />GENERATOR Generator completes la-r <br />• <br />• 4 0 <br />a. Generator's US EPA ID Number b. Manifest Document Number <br />_ <br />c. Page 1 of <br />d. Generator's Name and Location* <br />F . Phone: <br />— e. Generators Mailing Address- <br />,. <br />g. Phone: • If owner of the generating facility differs from the generator, provide: <br />h. Owners Name: i Owners Phone No.: . I I I <br />j. Waste Profile # k. Exp. Date I. Waste Shipping Name arid rri Contai ners n. Total a Unit 0 <br />Description Na I_ Type Duarte/ %%Vol <br />, <br />., <br />0 <br />4110 <br />410 <br />001 GENERATOR'S CERTIFICATION* I hereby certify that the above named material is not a hazardous waste as dermal by 40 CFR 251 7 any appicable <br />state law, has been properly described, classified and packaged, and is in proper condition for transportation according to acipTicable regulations AMID. d Its <br />waste is a treatment residue of a previously restricted hazardous waste subject to the Land Disposal Restrictions. I certify and warrant rat re mesa has <br />0 <br />been treated in accordance with the requirements of 40 CFR 268 and is no longer a hazardous waste as defined by 40 CFR 261 <br />1 • p. Generator Authorized Agent Name (Print) q. Signature 1 r. Date <br />II. TRANSPORTER (Generator completes Ila-b and Transporter completes Ilc-e) <br />Transporters Name and Address. <br />0 <br />Phone: <br />• 1 <br />Driver Name (Print) Signature I e. De.e. Ilit <br />III. DESTINATION (Generator complete Illa-c and Destination Site completes Illd-g) 0 <br />a. Disposal Facility and Site Address <br />b <br />c. US EPA Number d. Discrepancy Indication Scace <br />• <br />I hereby certify that the above named matenal has been accepted and to the best of my knowledge the foreooing s true and acr-rale. <br />0 <br />Name of Authorized Agent (Print) Signature Date <br />IV. ASBESTOS (Generator completes IVa-f and Operator complete 1Vg-l) <br />a. Operators Name and Address <br />b Phone: <br />c Responsible Agency Name and Address • <br />d. Phone 0 <br />e. Special Handling Instructions and Additional Information <br />• f 0 Friable 0 Non-Friable 0 Both % Fnable % Non-Friable <br />OPERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately desi. :bed above b re p--xie, s-icprc na-e,,. WI labeled/placarded, in in condition for transport and are classified, packaged, marked and and are all respects proper angto a;olcatire rrei.cr-a a-c <br />national governmental regulations, IP- <br />p. Operators Name and Title (Print) h Signature i Date <br />*Operator refers to the company which owns, leases, operates. controls or supervises the fealty owing dernoltred or renovated or re dendido-• • 41 <br />renovation operation or both <br />REV 04119 GENERATOR RETAIN <br />