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NON-HAZARD ' S SPECIALWASTE &, BESTOS MANIFE <br /> If waste Is asbestos waste, complete Sections I, 11, m ar�Orv. <br /> 0 it waste is NOT asbestus waste, complete only Sections I, H and M. <br /> :, EN ERATOR Generaw mrnnkim a�t <br /> Q g e U <br /> b. Generating Location: <br /> a. ener*or Name: / Fab <br /> �05/ .Q(�(1 d. Address: <br /> cddress: .41„r,/vCA <br /> ethone No.: Zli�2� I. Phone No.: <br /> Iner of the generating facility differs from the generator, provide: <br /> ner's Name: h. Owner's Phone No.: <br /> 5TYPE <br /> Q 191 <br /> DM-METAL DRUM <br /> i. Fl WASTE CODE 7 7 2 Containers pp -PLASTIC DRUM j <br /> B -BBAG <br /> Quanti un 'No. TYPE BA .6 MIL. PLASTIC BAG <br /> f escription of Waste: k or WRAP <br /> ,i 1 T -TRUCK <br /> AI HA?Z�_ Std/6 / fl OTHER <br /> I <br /> UMTS <br /> ENERATOR'S CERTIFICATION: I hereby certify that the above named material is not a hazardous waste as defined by 40 CFR Part 261 <br /> r any applicable state law,has been properly described,classified and packaged,and is in proper condition for transportation according to P -POUNDS <br /> kplicableregulations;AND,it the waste is a treatment residue of a previously restricted hazardous waste subject to the Land Disposal Y -YARDS <br /> M3-CUBIC <br /> Restrictions,I certify and warrant that the waste hes been tr in accordance with the requirements of 40 CFR Part 268 and is no longer Y3 -CUBIC YAROSS <br /> hazardous waste as defined by 40 CFR Part 281. ' fl -OTHER <br /> ' " FR Liv10M015 <br /> Generator Authorized Agent Name n ture Shipment Date <br /> s <br /> ANSPO : �►.r } <br /> tion II Generator complete <br /> RTER( a d; T.an n oam�aats <br /> TRANSPORTER I TRANSPORTER II <br /> me. <br /> tom+-cUQ�/ h. Name: <br /> _ <br /> fdress: PS 's' i. Address: <br /> 60,o -r-06e,' +C �1SJ Z <br /> river Name/Title: i. Driver Name/Title:. _ PRiNTITYPE <br /> 1Ie, <br /> d. Phone No.: <br /> /721-0/ 4 e, Truck No.: k. Phone No.: I. Truck No.: <br /> ��� <br /> aehicle License No./State: m.Vehicle License No.IState: <br /> cknowledgement of Receipt of Materials. Acknowledgement of Receipt of Materials. <br /> F ! n. F--E= <br /> Shipment Date Diner Signature Shipment Date <br /> Driver Signature "" � ,,i <br /> Ction MpESTINATION ((3a±zl►rator completes a d destirtetiaii site t mEtletes e ) * <br /> a (fi�Gi��zLL <br /> c. Phone ND. <br /> V7-4�Igl <br /> Site Name: S CQ : <br /> Physical Address: ' d. Mailing Address: <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 /> Name mi Authorized Agent <br /> Signature 7777777-/ Receipt Date <br /> 5 <br /> fction IV ASBESTOS (Generator complete 8_d:'fr g.Operatm complewss e. <br /> perator'sb Name: b. Operator's" Phone No.: <br /> Operator's' Address: <br /> . Special Handling Instructions and additional information: <br /> PERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are tully and accurately described above by proper shipping name and are classified, <br /> ked, marked, and labeled, and are in all respects in proper condition for transport by highway according to applicable international and government regulations. <br /> e. Oneratcr's Name & Title - <br />