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I. GENERATOR (Generator completes la-r 7.1)a • 4t:ier-4492 Transporter's Name and Address: I tat to iitiY crA Phone: IV. ASBESTOS (Generator completes IVa-f and Operator complete IVg-i) • REV 04119 GENERATOR RETAIN RS-FI1A • lk Pe REPUBLIC dAS SERVICES J147 a. Generators US EPA ID Number b. Manifest Document Number Page 1 of Generator's Name and Location: I,'-iA I Wakato.:, Ild 2.,:•::',...-:. ,!. ',-; f. Phone: Generator's Mailing Address: 1400 Ytitiludtk, k'd ',!, (.•. :.-. c.• r20. .‘ -..., :v, .1;2 g. PhO ne: !. If owner of the generating facility differs from the generator, provide: Ii. Owner's Name: i. Owner's Phone No.: j. Waste Profile # k. Exp. Date I. Waste Shipping Name and Description m. Containers n. Total Quantity o. Unit Wt/Vol No. Type Buineci Pids.iio Bins & Dried Tomatoei GENERATOR'S CERTIFICATION: I hereby certify that the above named material is not a hazardous waste as defined by 40 CFR 261 or any applicable state law, has been properly described, classified and packaged and is in proper condition for transportation according to applicable regulations; AND. if this waste is a treatment residue of a previously restricted hazardous waste subject to the Land Disposal Restrictions. I certify and warrant that the waste has been treated in accordance with the requirements of 40 CFR 268 and is no longer a hazardous waste as defined by 40 CFR 261. p. Generator Authorized Agent Name (Print) g. Signature r. Date DESTINATION (Generator complete lila-c and Destination Site completes Illd-g) Disposal Facility and Site Address- US EPA Number Discrepancy Indication Space: I hereby certify that the above named material has been accepted and to the best of my knowledge the fore oing is true and accurate. Name of Authorized Agent (Print) Signature q. Date NON-HAZARDOUS SPECIAL WASTE & ASBESTOS MANIFEST If waste is asbestos waste, complete Sections I, II, ill and IV It waste is NOT asbestos waste, complete Sections I, II and III • • • • • • a. Operators Name and Address: b Phone: Responsible Agency Name and Address: _ Phone: Special Handling Instructions and Additional Information: 1. 0 Friable 0 Non-Friable 0 Both % Friable % Non-Friable OPERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name and are classified, packaged, marked and labeled/placarded, and are In all respects in proper condition for transport according to applicable international and national governmental regulations. q Operator's Name and Title (Print) h. Signature I. Date 'Operator refers to the company which owns, leases, operates, controls, or supervises the facility being demolished or renovated, or the demolition or renovation operation or both • • I a. Date d. Signature c. Driver Name (Print) TRANSPORTER (Generator completes ha-b and Transporter completes 11c-e