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' NON-HAZARD • S- SPECIAL 'WASTE $c: BESTOS MANIFEST" ,,� <br /> If waste is asbestos waste, complete Sections I, 13, M and IV. No. <br /> If waste is NOT asbestos waste, complete only Sections I, Il and M. �. <br /> io I ENERATQR p <br /> enerator Name: +� <br /> �' b. Gene9 <br /> ratin Location: <br /> � <br /> 01/ <br /> fddress: d. Address: <br /> W51 17eu) � <br /> !�;fD(3)�Yiin C <br /> Shone No.:• �+� f/z 2- 0 f f. Phone No.: <br /> It owner of the generating facility differs from the generator, provide: <br /> .. . <br /> ner's Name: hOwner's PhoneNo: <br /> . TYPE <br /> (� J� /� DM-METAL DRUM <br /> i. BFI WASTE CODE Q © r ' 7171 T Containers gP -BLASTIC DRUM <br /> jescription of Waste: /V /� p�`- ©�`� ,o Ouantiunm No. TYPE BA 8 MIL. PLASTIC WRAP BAG <br /> t T TRUCK <br /> 4e- <br /> m � O -OTHER <br /> �ENERATOR'S CERTIFICATION:I hereby certify that the above named material is not a hazardous waste as defined by 40 CFR Pan 261 UNITS <br /> ir any applicable state law,has been properly described,classified and packaged,and Is in proper condition for transportation according to P -POUNDS <br /> applicable regulations;AND,It the waste In a treatment residue of a previously restricted hazardous waste subject to the land Disposal Y -YARDS <br /> Restrictions,I certity and warrant that the waste has been treated in accordance with the requirements of 40 CFR Part 266 and is no longer M3-CUBIC METERS <br /> hazardous waste as defined by 40 CFR Pan 261. Y3 -CUBIC YARDS <br /> O -OTHER <br /> Generator Authorized Agent Name ignature Shipment Date <br /> • . ., ,e"`t=rarlat I'C4mptetQ s•ff _ <br /> ctian II TRANSPORTER(Gerrerator complete sot" r nw tT complete n n) <br /> TRANSPORTER I TRANSPORTER II <br /> h. Name: <br /> *ddress: v e �' Q �Q I. Address: <br /> !? D / <br /> Driver Name/Title: -- ._4 I. Driver NamelTitle: ParNvrvPE <br /> �/ PRINTITYPE l <br /> d. Phone Na,:/`7 0�� 7 �- �9� e• Truck No.:e" �?5 k. Phone No.: I. Truck No.: <br /> X7 m.Vehicle License No.lState: <br /> ehicle License No./State: � � <br /> Acknowledgement of 190cei t of Materials. { Acknowledgement of Receipt of Materials. <br /> 6 © / n. <br /> Driver Signalure Shipment Date Dvtver Signature 5hinment Date <br /> r. <br /> t3Ction III _ :„ DESTINATION (Geneiatorr CDMrip/ietesiiad;tlastlnatfcui elle C late$04.) <br /> Site Name: nI 4Qr" " c. Phone Nv.: '��� <br /> b, Phsicel Address: qOO` Al ` 0"5 d. Mailing Address: - <br /> Y <br /> Discrepancy 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 /> f Name of Authorized Agent sig re Recelpt Date <br /> .ctifln IV A58ESTf1S tGerrerat to a-d.:t. <br /> perator's' Name: b. Operator's` Phone No.: <br /> Operator's' Address: <br /> d. Special Handling Instructions and additional information: <br /> ERATOR'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 /> rked, marked, and labeled, and are in all respects in proper condition for transport by'highway according to applicable international and government regulations. <br /> e Oopratnr'�* Name F. T rl <br />