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TRANSPORTER (Generator completes Ila-b and Transporter completes Ilc-e) <br />Transporter's Name and Address: <br />Phone: I <br />Driver Name (Print) d. Signature e. Date <br />14, <br />Raft <br />Ck, ee REPUBLIC' NON-HAZARDOUS SPECIAL WASTE & ASBESTOS MANIFEST <br />41,4 SERVICES <br />If waste is asbestos waste, complete Sections I, II, III and IV <br />H <br /> <br />If waste is NOT asbestos waste, complete Sections I, II and III <br />GENERATOR (Generator completes la-r) <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 />.. <br />f. Phone: <br />e. Generator's Mailing Address: <br />g. Phone: <br />If owner of the generating facility differs from the generator, provide: <br />h. Owner's Name: i. Owner's Phone No.: <br />j. Waste Profile # k. Exp. Date I. Waste Shipping Name and <br />Description <br />m. Containers n. Total <br />Quantity <br />o. Unit <br />Wt/Vol No, Type <br />-;.- ., • l i 'Ark ir'i • ..!-," rt r n, <br />r I r , <br />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 <br />state law, has been properly described, classified and packaged, and is in proper condition for transportation according to applicable regulations; AND, if this <br />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 <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 ., . • v , <br />Or),,.)i N. 1, it'',1,•-. ...--- , <br />, <br />: • ,?... % <br />p. Generator Authorized Agent Name (Print) q. Signature r. Date <br />DESTINATION (Generator complete lila-c and Destination Site completes Illd-g) <br />a. Disposal Facility and Site Address: <br />b, .•CP-t-Ig"?/0(ttl <br />c. US EPA Number Discrepancy Indication Space: <br />, <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 />Name of Authorized Agent (Print) Signature Date 1 <br />ASBESTOS (Generator completes IVa-f and Operator complete IVg-i) <br />Operator's Name and Address: <br />Phone: <br />c, Responsible Agency Name and Address: <br />d. Phone: <br />Special Handling Instructions and Additional Information: <br />111 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 />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 />REV 01/14 <br /> rtramw 10 or,EnAron <br />RS-F1 IA