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INS <br /> t <br /> ' NON-HAZARI JS SPECIAiLWASTE`ISS'RESTOS MANIFES- <br /> If waste is asbestos waste, complete Sections I,`II, ffi and]V. <br /> If waste is NOT asbestos waste, complete only Sections I, D and III. <br /> fie nerator Name: <br /> Address: <br /> L+/cam< i 17777777/,i �f / <br /> Phone No.: �I � Z f Z T Q I 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 /> BFI WASTE CODE Q 7 "Y Containers DM-METAL DRUM <br /> DP -PLASTIC DRUM - <br /> B -BAG <br /> Description of Waste: - r k. Quantity unit3 No. TYPE BA -6 MIL. PLASTIC BAG <br /> « ! or WRAP <br /> T -TRUCK <br /> O -OTHER , <br /> 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 POUNDS <br /> applicable regulations;AND,It the waste is a treatment residue of s previously restricted hazardous waste subject to the land Disposal Y -YARDS <br /> Restrictions,I certify and warrant that the waste has been treat m cccrdance with the requirements of 40 CFR Part 268 and is no longer M3-CUBIC METERS <br /> a hazardous waste as <br /> defined by40CFR Part 261. Y3 -CUBIC YARDS <br /> O -OTHER <br /> Generator Authorized Agent Name r Shipment Date <br /> k complete <br /> atpetCtlolu TRANSPORTER(Gerrerem t*�„} <br /> TRANISPORTER I TRANSPORTER N <br /> Name: �-�-[J Q-�/�I;L� //� /�'7 h. Name: <br /> ddress: 2 5g � � �. I. Address: <br /> Driver Namell I/►'6& Driver Name/T3tie: <br /> INTM'PE PRiNT <br /> d. Phone Na: (��iJ e.c",,Tr�ru k No.: k. Phone No.: I.. Truck No.: <br /> Vehicle License No.lState�p2?a 1 m.Vehicle License No.IState: <br /> Ac owledgem f eceipt of Materials. Acknowledgement of Receipt of Materials. <br /> ` P Q <br /> I Dr ignature Shipment Data n Ehrwar Signature Shipment Date <br /> Ct10Ft77 <br /> :' 'DESTINATION (Generator &4,oesttrfatksrt arrtpletea e f.} " w =�"EZ {� <br /> n. <br /> v. <br /> Site Name: CuLAPLLC�� c. Phone No.: 6 — V7- i�)q9/ <br /> Physical Address:— Y f / Q15Co `4014, Mailing Address: <br /> t ` <br /> Discrepancy Indication Space: <br /> hereby certify that the above named material has been accepted and to the best of my knowledge the foregoing is true and accurate. <br /> � l <br /> Name of Authorized Agent Signature Receipp Date <br /> r. <br /> t1olt IV ASBESTOS (Generator - e a g,opecert�r*R«rmp►ettis e} <br /> perator's' Name: b. Operator's' Phone No.: <br /> Operator's' Address: <br /> C _ <br /> fSpecial 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 /> eked. marked, and labeled, and are in all respects in proper condition for transport by highway according to applicable international and government regulations. <br /> e Operator's"' Name & Title: <br />