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F NON-HAZAREGA SPECIAL WASTE & &IESTOS MANIFEST <br /> If waste Is asbestos waste,complete Sections 1,II,III and IV. N O. 512407 <br /> If waste is OT asbestos waste,complete only Sections 1,II and III_ <br /> 3ectionI,' ' 4' . �"4X GENERATOR (deneraorcompletes all ofSection <br /> �q <br /> Generator Namee:: � 0 F=(iU.�CT% Cmc b. Generating Location: ,CO � P\TIGra <br /> Address CCC) toy 5y,-7 d. Address: L pt��(� <br /> b1cNA 'LAX-Y— . <br /> l�ACr-\F . C(A; �l�`�ZZ -SJ77 c�TJLK�uia 0, <br /> Phone No.:�� Z')l- 2)59111r AOI. JJmIc- f. Phone No.: <br /> owner of the generating facility differs from the generator,provide: <br /> ( \ <br /> Owners Name: �LC 1 R.t7�l1LTS `s-' -`YW^T"� (�h. Owners Phone No.: �r`l- <br /> TYPE <br /> BFI WASTE CODE ® q lJ Q 1 1 1 Z L7 Containers DM-METAL DRUM <br /> DP -PLASTIC DRUM <br /> B -BAG <br /> Description of Waste: t.1ctN- \'IeA�AQZoJS -S=�kt-- k. Quantity U© No. TYPE BA -6 MIL.PLASTIC BAG <br /> or WRAP <br /> r O -OTHER <br /> .GENERATOR'S CERTIFICATION: I hereby oer6fy that the above named material is not a hazardous waste as defined by 40 CFR Part 261 or i <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 regulations;AND,if the waste Is a treatmentyesa of a previout y restricted hazardous waste subject to the Land Disposal Y -YARDS <br /> Restdctfons,I cenify'and warrant that the waste has beep treated in aocordan the requirements of 40 CFR Part 266 and is no longer a M' -CUBIC METERS <br /> hazardous waste as defined by 40 CFR Part 261. Ys -CUBIC YARDS <br /> /A/w <br /> O -OTHER <br /> Generator Authorized Agent Name (Sign tore Shipment Date <br /> Transporter l comPlet V <br /> eCtiOT1 TI TRANSPORTER (Generatorcompletee-d; Trans rterIIcora let <br /> TRANSPORTERI TRANSPORTERII <br /> Name: 74L — 74 h. Name: <br /> Address: -4g"-e f A I. Address: <br /> Driver.N"erlieTntr'°x`"' �-{l:.,c.+ .f�.,.> J. Driver NameRttle: �`�,•,: ... :, .. <br /> y PRINTfMr PIUNTfrYPE - <br /> Phone No.: e. Truck No.: k. Phone No.: I. Truck No.: <br /> Vehicle License No./State: ` `E -- r } >f!' m.Vehicle License NoJState: <br /> Acknowledgement of Receipt of Materials. Acknowledgement of Receipt of Materials. <br /> n. <br /> ^ ; <br /> a <br /> Dm�6i nature ahi mens Date Direr signature Shi meet Date <br /> ection ZII DESTINATION (Generator completes a-d,destination site completes`e'-f`:) <br /> Site Name: tT \ )� �J 4 k��v r Ly'a\�fj�-�f r� k1,L, c. Phone No.: '�i Z-� �t`T 0%A0 k <br /> Physical Address: d. Mailing Address <br /> ` <br /> l-i:�t,\V\'1r'A l (A A,``,:,S0 <br /> .P,iscrepancy 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 />