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NON; HAZARC"SPECIAL WASTE & IWOESTOS MANIFEST <br /> r <br /> If waste is asbestos waste,complete Sections I,A,ID and IV. No- C A O C <br /> ,a If waste is NOT asbestos waste,codlplete only Sections I,II and III. �J s# v <br /> NERATOR '(Genemto(completes allot Section p <br /> ieneretor Name: (�_ .� \�) b. Generating Location: R��-' <br /> Wdresss[, 1�,^.► (A�y. 2377 d. Address. `. ANy.�%i\L - <br /> CA <br /> 'hone NO.: 7 G��� 2 ) �1 ��� 11 YAJI. •c..`.ltl -f. Phone No.: <br /> mer of the generating facility differs from the gene tor,provide:- <br /> THners Name: Ak(J SRU&Xt S C�c.,ny"y h. Owner's Phone No.: cCtQtf,u _ <br /> 3FI WASTE CODE FN ® 10 0 L � � 9 G L �€ <br /> Containers DM-METAL DRUM <br /> DP -PLASTIC DRUM <br /> B -BAG <br /> )ascription ofWaste: M'F1plW ✓,1L k' Quantity uBAG <br /> or <br /> N m O -OTHER WRAP <br /> Z <br /> GENERATOR'S CERTIFICATION:.I hereby certify that the above named material is not a hazardous waste as defined by 40 CFR Part 261 or UNITS <br /> any applicable state law, has been property described,classified and packaged, and is in proper condition for transportation according to P -POUNDS <br /> applicable regula0ons;AND,If the waste Ise treatmerkTf sidoe of h previously restricted hazardous waste subject to the Land Disposal. Y -YARDS <br /> Restrictions,I certify and warrant that the waste has bf¢n�eajed in accords g3ah the requltements of 40 CFA Part 266 and is no longer a M' -CUBIC METERS <br /> hazardous waste as defined by 40 CFA Part 261. 1r� f Ys -CUBIC YARDS <br /> 1 r , O 1 � i �, O -OTHER <br /> Generator Authorized Ag nt Name Si attire Shipment Date <br /> . . �4,-Jans rtlech1=41etee-9 . . <br /> CtiO31.II' ` TRANSPORTER (Generator complete ad ,T porterIIcom eteh�k}. <br /> T/R!-ANSPORT�E�R I f TRANSPORTER II <br /> lame: �/B�ii,E'cd& Sa w r rlL�rLGi✓r/t1//sem. In.,Name: <br /> Adress: i...Address: <br /> �riverName/ritle:.-,,._L�Ea,4-c,f.°1�.t/.;:.�. . J.:_RrtverName/iitle;. <br /> PalNTfrYPE (-7 PRINT/IYPE <br /> hone No.:�!�� ?=/ � ' 0 e. Truck No.: 7 - k. Phone No.: I. Truck No.: <br /> ehicle License No./State: %'> >��S r^ .-f m.Vehicle License No./State: <br /> cknowlgement of Receipt of Materials. Acknowledgement of Receipt of Materials. <br /> 7 <br /> n. <br /> wer Si nature Sir ment Date Dmer Si raem Shi=rt Date <br /> ;tion III DESTINATION (Gen mtorwmpletesa-d,destinaVonsftewmpletese-t.3.- , <br /> ite Name: -iJ� n\ - '�`t,A� dRrd C(Pv�h)� p�n1DF tib Phone No.: LS — 1 — l 1 1� <br /> hysicel Address: iA\t-'f`-J lyykQkU ' 'flXD d. Mailing Address ��l'I:..>i( �(V+ •1 C� --t:C��'> <br /> C <br /> iscrepancy Indication Space: <br /> iereby certify that the above named material has been accepted and to the best of my knowledge the foregoing is Srue and accurate. <br /> _. 1 ] it✓JN IINe .. <br />