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t7 .` ' NON-FIAZAR106S SPECIAL &ft13_*ErST0' S,MANI,F�rr EST. , If waste is asbestos waste, complete Sections I, 11, III and IV. No. It waste is NOT asbestos waste, complete only Sections I, 11 and III, " f ENERATOR �t eneratof Name: b.b. Generating Location: �Ci � c. Address: _ Q S[ P � d. Address: oS) N��N hone No.: l (6 51-7 f. Phone No.: It owner of the gengrating facility differs from the generator, provide: #Wner's Name: h. Owner's Phone No.:ll ,�` 141'7kT74�1 TYPE i. BFI WASTE CODE 1013131 1 '1 Containers DM-METAL DRUM DP -PLASTIC DRUM B -BAG ilDescription of Waste: ON �R-Rd Dkf 1 �s k. Quant* units No. TYPE BA -& MIL_ PLASTIC BAG or WRAP T -TRUCK V O =OTHER GENERATOR'S CERTIFICATION:t hereby certify that the above named material is not a hazardous waste as de fined by 40 CFR Part 261 - UNITS or any applicable state law,has been properly described,classified and packaged,and is in proper condition for transportation according to P -POUNDS applicable regulations:AND,It the waste Is a treatment residue of a previously restricted hazardous waste subject to the Land Disposal Y YARDS estrictions,I certify and warrant that the waste has been treat in accordance with the requirements of 40 CFR Part 268 and is no longer M3-CUBIC METERS hazardous waste as defined by 40 CFR Part 261. Y3 -CUBIC YARDS O -OTHER �tr�rtiT K�rzL�,v 4 � Generator Authorized Agent Name ure shipment Date #ion II TRANSPORTER(Generator complete T �,,,,�1«,e } . i£cortq�su is sr �•.. .. / TRANSPORTER I TRANSPORTER 1I Wme: /e 4L ¢L ' C k 1,vii4 h. Name: b. Address: Z S 3 0 7R,E ,R ZD i. Address:r 5l 4,^j T Driver Name/Ti a: vrat,73Y a i. Driver Narne,Mtle: PRIWT1TdPE Phone No.: r-+� e. Truck No.: k, Phone No.: I. Truck No.: Vehicle License No./State: �^r ?� �2 m.Vehicle License IState: Acknowl errant of Receipt of Materials. �j q Acknowledge ent of Receipt of Materials. ZK" © ! 1 n. shipment Date Dwer signature shipment Date Dr ver s+gnatum _ Section III Site Name: : ✓=-L sT; `'_-3 DESTINATIO/N,,(i emor- etas er�c[;d lore site�rnp�te�a�. CC /Q"N f � Z4 mi F L c. Phone No.: ,rte b. Physical Address: DD I i4S'' C d. Mailing Address: ..,_H 41. e. Discrepancy Indication Space: I hereby certify that the above named material has been accepted and to the best of my knowledge the foregoing is true and accurate. f Name of Authorized Agent Signature Recelpt Dale tion IV ASBESTOS {4e►�erator complete ate,t, ttp+xarur�; un±pyatgs e}.. � .. perator's* Name: b. Operator's" Phone No.: O cperator's** Address: d. Special Handling Instructions and additional information: JERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by proper shipping name and are classified, cked marked and labeled and are in all respects in proper condition for transport by highway according to applicable international and government regulations.