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r NON-HAZARDOUS SPECIAL WASTE" SBESTOS MANM. 1� <br /> If w e Is asbestos'waste, CompleteiSectiorta i ff <br /> r } andI -No e' ;Z46 <br /> 163 4w, <br /> If waste is NOT asbestos waste temENEplate 11rtly <br /> Swticm <br /> i lI tendIII <br /> 0 1 - <br /> Genettar Name: ! I �4 b. Generating Location: a CtT 7 <br /> Address: —T I e w ,2 pa d Qsl �e cvr, sad <br /> d. Address:A L" -tD 47, <br /> e. Phone No.: r' — Z Z— f. Phone No.: <br /> owner of the generating facility differs from the generator, provide: <br />,t{ <br /> Owner's Name: h. Owner's Phone No.: <br />"F BFI WASTE CODE J(' J /�}� (� �G �/ TYPE <br /> Containers DM-METAL DRUM <br /> DP -PLASTIC DRUM <br /> j. Description of Waste: ©IV /� QQ �(� $ J Quanti 8 BAG <br />' units No. TYPE BA -6 MIL. PLASTIC BAG <br /> or WRAP <br /> a / T -TRUCK <br /> E ( 0 -OTHER <br /> I GENERATOR'S CERTIFICATION: I hereby certify that the above named material is not a hazardous waste as defined by 40 CFR Part 261 UNITS <br /> or any applicable state law,has been properly described,classified and packaged,and Is in proper condition for transportation according to p <br /> -POUNDS <br /> applicable regulations;AND,If the waste Is a treatment residue of a previously restricted hazardous waste subject to the Land Disposal Y -YAARDS <br /> i Restrictions,I certify and warrant that the waste has been treats accordance with the requirements of 40 CPR Part 268 and is no longer M3- <br /> a hazardous waste as defined by 40 CFR Part 261. CUBIC METERS <br /> 3 CUBIC YARDS <br /> -OTHER <br /> 0 <br /> enerator Authorized Agent Name a ure <br /> Shipment Date <br /> action II <. , ORTER ftator aoatptete f►rt <br /> L►Gt-�Q.al��NSPORTER I <br /> r, .,� TRAN�'ORTER II <br /> Name: 7_ru .A<J17 h. Name: <br /> ddress: S r es5a., �Q I. Address: <br /> ACA 9-9-189 <br /> U5E' <br /> c. Driver Name/Title: t, 'JL/ <br /> r,/�/PRtNT1TYPE 1• Driver Name/Title:_ <br /> ' ~J 7-iJ/ (I PAINTJTYPE <br /> Phone No.: . Truck No.: =�/ k. Phone No.: <br /> I. Truck No.: <br /> f. Vehicle License No./State: 3 m.Vehicle License No./State: <br /> Acknowledgemen of Receipt of Material Acknowledgement of Receipt of Materials. <br />--- Driver Signature , ,- n <br /> Shipment Data <br /> tknror Signature EEE:= <br /> ctlor� III , DESTfNAT10N ( rtur' R t s b Shipment Date <br /> - rt oomple t1if.destirlafia n completes. _ /}�/`-�c3a ; a <br /> a. Site Name. Q5C D t ; /'l1*ar C_Iltl 4_U c. Phone No.: 'J�+ �� 0419 t <br /> 'Physical Address::_ 100/ 'A-1. a (�, ( /��Q - d, Mailing Address: <br /> V�rrY1p <br /> Discrepancy Indication Space: ; <br /> i' <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 /> Eff:�Name at Authorized Agent Signature //? <br /> / Receipt Date <br /> Section IV <br /> et3 <br /> ASBESTOS t,ar "nor;, <br /> t a%d,t,�taeoi'"'aornc�etea e.} _fRAerator's' Name: b. Operator's' Phone No:.:erator's' Address: <br /> ecial Handling Instructions and additional information: <br /> TOR'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 /> packed, marked, and labeled, and are in all respects in proper condition for transport by highway according to applicable international and government regulations. <br /> 11 perator's' Name & Title: <br /> Prinli Type Operators Signature <br /> t Name and Address Date <br /> tri_ <br />