10003_ROSCANS_2008

N Complete items 1, 2, and 3. Also complete
item 4 if Restricted Delivery is desired.
® Print your name and address on the reverse
so that we can return the card to you.
® Attach this card to the back of the mailpiece,
or on the front if space permits.
1. Article Addressed to:
Ray Hoffman -
Republic Services, LLC
P.O. Box 2943
Hickory; North Carolina 28603-
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A. Sig 'ture
sL7 Agent
❑ -Address
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C. nDaate of De iv
D. Is delivery add different from. item
1? ❑ Yes
If YES, enter delivery address below: ❑ No
3. Service Type
Certified Mail ❑ Express Mail
❑ Registered ❑ Return Receipt for Merchand
❑ Insured Mail ❑ C.O.D.
--- - --- - 4._ Restricted Delivery? (Extra Feel ❑Yes
2. Article Number 7006 3450 0002 7064 .9959
(rransfer from service labeg
PS Form 3811, February 2004 Domestic Return Receipt io2595-02-M-1
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Total Postage &Fees
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Republic Services
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Sent To
Ray Hoffman
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Republic Services, LLC _--•-
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Streef, Apt lJo:
or PO Box No.
P.O. Box 2943
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STAT
INCORPORATED
CERTIFICATE OP' DISPOSAL
STAT, INC hereby certifies that the following shipment of
Waste was disposed according to North Carolina law
Receiving date-3/19/2008
ITEMS Received for disposal or recycling as listed
Received 2,000 gallons of oily water for solidification to bo; disposed of at the local
landfill ---- Republic landfill (Foothitls)
Certificate issued to :Burnsville CT Landfill
BY; Kathy Eckard offiice.Manager DATE: 3/19/2008
Post Office Box 1443 • Lenoir, N.C. 28645 • Telephone [phone] • Fax [phone]
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NOWHAZARDOL,33 WASTE MANIFEST
-XintorlYPO. (Form designed for usza an 91he (12 pitch) typewriter)
NON -HAZARDOUS
WASTE MANIFEST
1, Ganeralor's LIS EPA 10 No.
Manifest
DoGurnant Np.
2. Page I
Of
1,38neralor's Na "a Mailing wet d M of
IQ' V C
6enerato(a Phone
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S. Transporter 1 Compaq N4ma U�EPA 10 Number
A. Slate TryinortsrF ID
S. Transporter I Phone
C. State Tearfspommes 10
7. Transporter ?Company Name 8. US EPA ID Number
D. Traotporter 2 Phone
P. Designated Facility Name and Site Address 10. US EPA it) Number
E. State Faclilly's ID
P. ratcIlIty's Phone
"I WASTE DESCRIPTION'
.12. Containers
No. Type
73.
Total
Q.srfily:
14,
UnIt
wtivol.
. .... �148tvonal �DascrfptlonOor Materials �Latid
H. Handling Codes lot WM" WOd Abovi
'i. flpedill FIBACIlieIg f0:WudIun$ and A0411tIonal inforfnailDn
5 IQ. GENERATOR$ CERTIFICATION; I hereb(certily that the contenta of We sh,imem are Tully and a—rately d-crib2d and era In I11 nQ2PQCtQ
I)rOpe e
r condition for transport, The mater 1318 described on this manifest are rot subject tj halafdous wove regulations.
`;%.--t9,5ffyp9d Name
•
Signatt:8"....
T,111P.1111 I ACI(n=j.m.AL of ClBipt Of Male('lal8
F,,:.lwQTyp&d Name %
11 "r-inspQrter 2 Acknowledgement of Receipt of Materials
Name I signalu, 5
j. Discrepancy Indication Space
-7-ciliry Owner of Operator; Certification of raCeipt of the waste materials covered by [hie manifest, except as noled in i 12.
Pr-r-tedlTyped Name Signature
4. 2002 llAbEAAVM 0 (800) 921-581511 —.I.b0rnA6t0,CO.
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Dale
Month Day YeArt
Date
Month Day Year
Datj
Month Day Year
I Date
Month Day YeAr
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04/01/2008 2V 9:16 FAX
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04/01/2008 TUG 9:16 FAX
STATC. Profific-swbe-t-
►�1 Conatitnenta (i4 gt Total 199N/
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I eertity Abat all Ingorwatto» form to complete and fecutul (lnctudiug attached information) andd is an
ee ra.11c representatl of. thown anti suspected hazards of tht wasitc to be disposed.
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4~e :fox #1443 Levoir, NC 28645 *Tel [phone] Fax [phone]
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