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_-p <br /> N4N-HAZARD S SPECIAr 1�V'ASTE BE <br /> MANIFEST <br /> 4 Na. <br /> 606170 <br /> N waste is asbestos waste, complete Sections >t,III and IV. <br /> If waste is NOT asbestos waste, complete only Sections T, H and M. <br /> tion 9*04HERATO'R: <br /> Generator Name: ,9 b. Generating Location: <br /> d �faS� 1 'Gc1 Lida / <br /> Adress: d <br /> i'1r,�-fan 4ad' <br /> . Address: <br /> CW <br /> Phone No.: L QZ f, Phone No.: <br /> owner of the generating facility differs from the generator,. provide: <br /> Owner's Name: h. Owner's Phone No.: <br /> TYPE <br /> ] 7 2 Containers DM METAL DRUM <br /> i. BFI WASTE CODE � [ 1. . <br /> O DP PLASTIC DRUM <br /> B -BAG <br /> _ <br /> Quantity Units No. TYPE BA -6 MIL. PLASTIC BAG <br /> k <br /> Description of Waste: or WRAP <br /> �te� ` T -TRUCK <br /> /V a A/r 1f fiq Zf�}K�©�S � fJ/L O -OTHER <br /> — UNITS <br /> GENERATOR'S CERTIFICATION: I hereby certify that the above named material is not a hazardous waste as defined by 40 CFR Part 261 <br /> or any applicable state law,has been property described,classified and packaged,and is in proper condition for transportation according to P -POUNDS <br /> applicable regulations;AND,if the waste Is s treatment residue of a prevlously restricted hazardous waste subject to the Land Disposal Y -YARDS _ <br /> Restrictions,I certify and warrant that the waste has been treat a a rdance with the requirements of 40 CFR Part 268 and is no longer M� _CUBIC BIC METERS <br /> YARDS <br /> a hazardous waste as defined by 40 CFR Part 261. 11� O OTHER <br /> Tg4z,T KTf4e t/,� <br /> .&L_ <br /> Generator Authorized Agent Name Signa a Shipment Date <br /> TfammxX6er i'cwroets e g <br /> Ction II .,;., . $PORTER{Geneft�tar ooatplete a-r�'T'tansporter-t7•eornpiere t►-n} - _�__, _..-..�,. <br /> TRAN/SPPO�RTER I� TRANSPORTI R II <br /> ame: �C�l� /` e✓\sr� h. Name: <br /> 1 —� <br /> ddress: � Q orf CS Sa 0�� L Address: <br /> .q_ -12 Z <br /> - — �� --� 1 7 <br /> Driver Name/Title: Driver-NamelTitle:pql T/TYPE - ----""�—PRWTITYPE <br /> d. Phone No.: - <br /> C7t / 7cr� Truck No.: k. Phone No.: f. Truck No.: <br /> _ <br /> Vehicle License No.iStale: m.Vehicle license No.IState: <br /> Acknowledgement qJFeceipt of Materials. Acknowledgement of Receipt of Materials. <br /> Lr � <br /> ` n. <br /> iver nalur DESTINATION <br /> ��� Shipment Dare privet Signature <br /> Shipment Date <br /> ectinn in ae <br /> e;1-1'_' NATION//(generator c mpletes'a 8lki[t,destlnits cttntptetea s l�/, 0/]//�+� <br /> Cd l yar !_-i C� t`P.c-{c. Phone No.:.� 51e) 4(417 4/1 Z <br /> Id.Site Name: <br /> b. Physical Address: <br /> Mailing Address: <br /> Lf Gr ter . u i <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 game of Authorized Agent - Signature Reaeipi Date <br /> ASBESTOS (rdeneratnr a f,4tues e.j <br /> f <br /> tion IVperator's" Name: b, Operator's" Phone No.: <br /> perator's" Address: <br /> d. Special Handling Instructions and additional information: <br /> 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, <br /> cWked,marked, and labeled, and are in a <br /> ll respects in proper condition for transport by highway according to applicable international and government regulations. <br />