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' NON-HAZARDOUS SPECIAL WASTE-& ASBESTOS MANIFEST <br /> r <br /> If waste is asbestos waste complete Sections I, n, III and rV NO. 606114 <br /> If waste is NOT asbestos waste, complete only Sections I, II and HI <br /> fddress <br /> rIon I. GENERATOR <br /> nerator Name Q �T'G �G l b Generating Location �Q s� /(� ZZ <br /> f 4/q d Address / �T �s/11e C-C�/1 <f-, <br /> hone No ( 7 ��J/ v� t/Q Q��p�, f Phone No <br /> I <br /> hone <br /> of the generating faculty differs from the generator, provide <br /> IFI <br /> wner's Mame h Owner's Phone No <br /> TYPE <br /> WASTE CODECIL Q I __RFI f . �S 9 Containers DM-METAL DRUM <br /> DP -PLASTIC DRUM <br /> B -BAG <br /> escnphon of Waste �DA/ /3Z LI.S Sd/G k Ouanti units No TYPE BA -6 MIL PLASTIC BAG <br /> mO -OTHERr WRAP <br /> ENERATOR S CERTIFICATION I hereby certify that the above named material is not a hazardous waste as defined by 40 CFR Part 261 UNITS <br /> any applicable state law has been properly described classified and packaged and is in proper condition for transportation according to P -POUNDS <br /> plicable regulations AND,If the waste is a treatment residue of a previously restricted hazardous waste subject to the Land Disposal Y -YARDS <br /> Restrictions I certify and warrant that the waste has been treated in accordance with the r uirements of 40 CFR Part 268 and is no longer M3-CUBIC METERS <br /> a hazardous waste as defined by 40 CFR Part 261 Ys -CUBIC YARDS <br /> O -OTHER <br /> _ ST <br /> Generaat r Authorized Agent Name Signatur Shipment Date <br /> Ir—ion II TRANSPORTER(genera w complivee'std, "anM7oi0a` <br /> TRANSPORTER I TRANSPORTER II <br /> i Name _ �il� LL� <br /> /� h Name <br /> dress S 8�'r ess ex- /C Qod i Address <br /> Iver Name/Title j Driver Name/Title <br /> 2�4?_o/ (TYPE ``� - fi PRINT ITYPE <br /> one No l -7�J� Truck No c`' k Phone No / I Truck No <br /> Ncte License No /State m Vehicle Lice No /State <br /> CknowI d ement of Rec t Materials 7 Ackntswl gement of Receipt of Materials <br /> 1 h rt <br /> 1 1 1 1 1 1 1 <br /> r Signature Shtpment Date shipment Date <br /> Ion III <br /> DESTINATION m / sedenva nn/pCleatas►a-f) <br /> CS <br />'lite Name esU0' X-'0 Lf � rZlc Phone No qqm7,-0 <br /> hysical Addr <br /> Y00 A • •`5(?�O 'Ae�"d Mailing Address <br /> 44-e rip Or G <br /> t liscrepancy Indication Space <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 /> All W F41 167Y <br /> Name of Authorized Agent Signature Receipt Date <br /> 3WIton IV ,' ASBESTOS (Generator oontpiste ad.f,e.Opwaw*ootttpletee e) <br /> Aerator's' Name b Operator's* Phone No <br /> orator's' Address <br /> I ecial Handling Instructions and additional information <br /> 7PERATOR S CERTIFICATION I hereby declare that the contents of this consignment are fully and accurately described above by proper shipping name and are classified <br /> eyed marked and labeled and are in ail respects in proper condition for transport by highway according 10 applicable international and government regulations <br /> Aerator s' Name 8 Title <br /> I <br /> P �ii' ce Operators SignZiure Oate <br />