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®-,NON-HAZAR S.SPECIAL:WASTE I&ABESTOS MANIFEST <br /> ''If waste+Is asbestos waste,complete Sections 1,IL ilI and IV. wl O� 5 240 p <br /> If waste Is NOT asbestos waste,complete only Sections I,II and III. N .LG O <br /> a. Generator Name: -A?X -t t4 ' I.D <br /> 0 -al� �� ,MgrAr`tl b. Generating Location: hw-`o. �-mc Z' <br /> 5 <br /> ( <br /> c. Address >o � SO-7-7d. Address: 16 - E. T�NFbyJ� <br /> �3CRt4N (Kcz�-, CA, 4obZZ A CA _ <br /> e. Phone No.: l1;5 - 2)9 - a09 PAIL fAJpPLC- I. Phone No.: N(A <br /> If owner of the generating facility differs from the generator,provide: Cn <br /> g. Ownet's Name: 7'\RL� K+-� w�PpWV h. Owner's Phone No.- `\Me <br /> .1 '1 F /� TYPE <br /> I. BFI WASTE CODE G` O S D tp 9 9 Containers DM-METAL DRUM <br /> DP -PLASTIC DRUM <br /> i�nf 1. ANZAQDWS ZO\I, e -BAG <br /> j. Description of Waste: k. Quant' 1 Units No.N�o. BA -6 MIL.PLASTIC BAG <br /> or WRAP <br /> Q y Q , r T -TRUCK <br /> O -OTHER <br /> GENERATOR'S CERTIFICATION: 1 hereby certify that the above named material is not a hazardous waste as defined by 40 CFR Part 261 or UNIT <br /> 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,If the waste Is a treatme sidup of a pre viou ly strlcted hazardous waste subject to the land Disposal Y -YARDS <br /> Restrictions,I certify and warrant that the waste has at¢fd in accord the requirements of 40 CFR Part 268 and is no longer a M' -CUBIC METERS <br /> hazardous waste as defined by 40 CFR Part 261. Y' -CUBIC YARDS <br /> O 3Ci O -OTHER <br /> Generator Authorized Age t1, ignaWre Shipment Date <br /> vsr5ti a 4�. :sr., � z ..,. .. s.'.<. W^ry c�'�='•t � ' COnI w'.� :�nev.'ss ��. } .�� .� ., <br /> y TRANSPORTERI - TRANSPORTERH <br /> /� <br /> a. Name: / l.t i/A/dI 7n,-. h. Name: <br /> TAr1 <br /> b. Address: ave-, " W I. Address: <br /> Y.-C-n �'A <br /> c. Driver Name/Title: C.Q A.. S A WAIS1011 - j, Driver Name/TItIw. - <br /> PRIN - <br /> TITYPE- PRINT/TYPE <br /> d. Phone No.: { -6Ge 67 S-i G 66 e. Truck No.: 6 f k. Phone No.: I. Truck No.: <br /> f. Vehicle License No./State: 5)4LI5 3S 9 04 m.Vehicle License No./State: <br /> Acknowledgement/of Receipt of Materials. Acknowledgement of Receipt of Materials. <br /> 101617-13111-:1 n. <br /> Omier S' re SN meet Dale Driver SI nature S Date <br /> '�if��'�,.- ^,-c <br /> a. Site Name: `k'ZLO VOND S&Ir4 nF AtAr Phone No.: "� 1�—�Lo, r9 <br /> b. Physical Address'. ��� N ��k� �� d. Mailing Address t`�• V��O hc..�A� <br /> CA 94SsD <br /> e. 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 />