INSTALL_1995 - Laserfiche WebLink

Home Browse Search

r �UtV NON-HAZARD S SPECIALWASTE -1 , �ST OS- AN: TFE_ T � ,IV 0.eP ' NIf waste is asbestos waste, complete Sections I,[IN T If waste is NOT asbestos waste, complete only Sections I, H and III.MINE *. GENERATOR +eanarator �cJk, i` b. Generating Location: Q N 1I nerator Name: I jam( n 4ddress: IL/I `y��n � d- Address: s _ . *hone No.: I. Phone No.: Awner of the generating facility differs from the generator, provide: g Owner's Name: h. Owner's Phone No.: �tTYPE � . IFI WASTE CODE Q ( `f 7 Containers DIM-METAL 5RUM DP -PLASTIC DRUM 6 -BAG /l/QAJ /�-,47�g,21}}t�k S 4/L k. Quanta units No. TYPE BA 6 MIL. PLASTIC SAG fescription of Waste: or WRAP mf T TRUCK O -OTHER -ENERATOR'S CERTIFICATION:I hereby certify that the above named material is not a hazardous waste as defined by 40 CFR Part 261 UNITS rr any applicable state law,has been properly described,classified and packaged,and is in proper condition for transportation according to P -POUNDS plieable regulations•,AND,It the waste Is a treatment residue of a previously restricted hazardous waste subject to the Land Disposal Y -YARDS Restrictions,I certify and warrant that the waste has been tree in accordance with the requirements of 40 CFR Part:268 and is no longer Ms-CUBIC METERS a hazardous waste as defined by 40 CFR Pan 261. fill Y3 -CUBIC YARDS O OTHER D d enerator Authorized Agent Name ature Shipment Date Cfiof� II TRANSPORTER Geneiatoi " a ;"'-tra ` coR fete hepvrter Ii opmplets�I 1 (2 TRANNSPORTER I /� ( TRANSPORTER II a. Name: r/I ar.—'ji l�� h. Name: dress: 953D r✓e 5-50— R&d_ i. Address 4river Name/Title: J. Driver NameMtle_ CIO r� (NT 111E PRINT I TYPE d. Phone ND.: ` ( 'L � e• Truck No.: it. Phone No.: I. Truck No.: chicle License No.lState: C r 2" CA m.Vehicle License No.IState: Acknowledgement of Receipt of Materials. Acknowledgement of Receipt of Materials. Le, �f' 10 1 1l 9 Jillill I In. FF I I I= Driver Signature Shipment Date Driver Signature Shipment Dale DES'fNAT10N for co npfetsa g it,castlnation sitfnps'e f.} ctfon ffi ��' . 'rr (Glaciers tL/ ite Name: a r rn c. Phone No.: 5/0r V hysical Address: f r Sil d. Mailing Address: Li or -. Discrepancy Indication Space: hereby certify that the above named material has been accepted and to the best of my knowledge the foregoing is true and accurate. FT�[�5 1 Name of Authonzed Agent Signature Receipt Date Ction N ASBESTOS (Generiator complete aOperator's ddrn*16' o.) peratol Name: b. Operator's' Phone No.: Operator's{ Address: Special Handling Instructions and additional information: OPERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by proper shipping name and are classified, ked, marked, and labeled, and are in all respects in proper condition for transport by highway according to applicable international and government regulations. e Operator's' Name & Title: