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ki <br /> NON-HAZARDOUS SPECIAL WASTE & ASBESTOS MANIFEST <br /> r <br /> If waste is asbestos waste Complete Sections I, II, III acid IV, No. 606112 <br /> If waste is NOT asbestos waste complete only Sections I, R and III <br /> ct1On x GENERATOR711 <br /> r <br /> l (oet►era#pr aaitlplriaR N t7f _� *"s� ...rrc; �a t•� r b w <br /> ngl�ttor Name d, Be 1 <br /> �/ ��h l� b Generating Location Q'{l�T`j(J /_ J <br /> ddtless CO / �(1�� /�S/7/� L!,(17 <br /> �� d Address <br /> S < C'a . S7t) ItF�? a <br /> thone Na YDB ���� Q 7�g OICp ~ 00/ <br /> ner of the generating facility differs from the generator, provide f Phone No <br /> 9 Owner's Name <br /> h Owner's Phone No <br /> IF] WASTE CODE (�, TYPE <br /> Containers LB <br /> -METAL DRUM <br /> �1 L <br /> UM <br /> I ascription of Waste Y 1��/ f�i$Z/�}/�Q des s'��(k. Ouantl thins No TYpE TIC BAG© APLIfIII <br /> GENERATOR S CERTIFICATION thereby certify that the above named motorial is not a hazardous waste as defined by 40 CFA Part 261 UNITS <br /> ap'211ib"llp"'.0gulations <br /> able state law has been property described,classified and packaged,and es to proper condition for transportation according to P -POUNDS <br /> stnetiionsI certify and warrants hatathe wase hste is a aas been tment residue <br /> treated m accordance with the ed hazardous <br /> sofWaste <br /> Ssubject <br /> R P�1 6t and y noispo al Y -CUB CUBIC a hazardous waste as defined by 40 CFR Part 261 longer <br /> /`�' Ys -CUBIC YARDS <br /> .CL` S' - E <br /> 2 Z 9 O -OTHER <br /> aerator Authorized Agent Name 5ignat <br /> Shipment Date <br /> lection TRANSPORTER(Gierwator coRoees a4 raryvortar fi°Oiiii" •}0h{f <br /> r <br /> ` TRANSPORTERI <br /> ame TRANSPORTER II <br /> N <br /> C h L -.� <br /> flame <br /> dress �S in 6 ;, /" P.;$CL Address <br /> ,7"�s e �a si3a <br /> Iver Name/Title <br /> iNTrTYPE r 1 Driver Name/Title <br /> a � /� \� PRINT/TYPE <br /> one No PRa Truck No `(f k Phone NNO,r/ I Truck No <br /> Vehicle License No /State m Vehiclw License No /State <br /> !kZnowlement of Receipt of Materials Acknowledgement of Receipt of Materials <br /> I <br /> F, <br /> sigwtwe n <br /> Shrprrtartt Dara Driver Signature Dau <br /> IOn jII DESTINATION (4enmator completes ad,deanaum ti�te"Maple//b''e e�) - -' : f _ <br /> Site Name C S h/ r G� L�h� Cc Phone No <br /> lysical Address `� �00�d Mailing Address <br /> crepancy Indication Space <br /> ereby certify that the above named material has been accepted and to the best of my knowledge the foregoing is true and accurate <br /> e of Authorized Agent Signature ROcelot Date <br />?ction IV ASBESTOS (Generator compiti a asf,f,i Operator*Completes e <br /> erator s* Name b Operator's" Phone No <br /> erator s' Address <br /> ecial Handling Instructions and additional information <br /> ITITATOR S CERTIFICATION I hereby declare that the contents of his consignment are fully and accurately downbed above by proper shipping name and are classified <br /> ked marked and labeled and are in all respects in proper condition for transport by highway according to applicable international and government regulations <br /> erator s" Name & Title <br /> ^ __ vont r Tvpe Operators Sigmture Date <br />