Laserfiche WebLink
a. Girerator's'US EPA ID Number • <br />- b. - Manifest Document Number <br />c. Page 1 of <br />d. Generator's Name and Location: <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: - <br />i. Owner's Phone No.: <br />j. Waste Profile # <br />k. Exp. Date <br />I. Waste Shipping Name and <br />Description <br />m. Containers <br />n. Total <br />Quantity <br />o. Unit <br />WWoI <br />No. <br />Type <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 />p. Generator Authorized Agent Name (Print) <br />q. Signature <br />r. Date °{ <br />. -. d _ <br />a. Operator's Name and Address: <br />b. Phone: <br />c. Responsible Agency Name and Address: <br />d. Phone: • <br />e. Special Handling Instructions and Additional Information: <br />f. ❑ Friable ❑ Non - Friable ❑ 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 />g. Operator's Name and Title (Print) <br />h. Signature <br />i. 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 />REPUBLIC NON- HAZARDOUS SPECIAL WASTE & ASBESTOS MANIFEST <br />SERVICES <br />380584 <br />_r) <br />a. Transporter's Name and Address: <br />b. Phone: <br />c. Driver Name (Print) 6, , , .' .. <br />e. Date <br />it <br />II. <br />d. Signature / <br />III. DESTINATION (Generator complete Illa -c and Destin Site cof pletes lild g) <br />d. Discrepant Indi tion Space: <br />- 1,r <br />a. Disposal Facility and Site Address: <br />e. Name of AGth orl±e6 Agent (Pn r(t)' <br />c. US EPA Number <br />I hereby certify that th e ve`nam d ate a has been accepted and,t %ttae lest of rroirnewledge the foregoing is true and accurate. <br />f. Signature <br />q. Date <br />SRESTOS (Generator completes IVa-f and Oper t6r complete IVg -i) <br />REV 12/10 <br />TRANSPORTER (Generator completes Ila -b and Transporter completes Ilc-e <br />, If waste is asbestos waste, complete Sections I, 11, III and IV <br />If waste is NOT asbestos waste, complete Sections I, II and III <br />TRANSPORTER RETAIN <br />RS -F11A <br />