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r - <br /> NON-HAZARDIA' SPECIAL WASTE 8& JI&STOS MANIFEST <br /> If waste is asbestos waste,complete Sections I,II,111 and IV. O• w e� OC <br /> If waste is NOT asbestos waste,complete only Sections 1,11 and III. NN 1 L J <br /> �G'`IENERATOR""'( enereiorcompleieseiioiSealonp" _'`t 1r; + • <br /> Generator Name: f�1qq��.U \l��K- W;'t'" b. Generating Location:�R(.3 <br /> Address VD �.Q.J� �Jl��� d. Address: \(0 %E <br /> b')C'WA PAa� . C& 9oaaz- <br /> Phone No.: 72�� 2.��� - �l�y( 1"AJV- �+t Y L Phone No.: N(A <br /> )wner of the generating facility diff rs from the generator,provide: <br /> Owners Name: . (b15C- 5- C�.�ANy h. Owners Phone.No.: <br /> TYPE <br /> BFI WASTE CODE C A (� c) b 0101 � 0 1 Containers DDM-METAL DRUM <br /> P -PLASTIC DRUM <br /> B -BAG <br /> Description of Waste: J-aA2kPxY, SOIL k. Quant Units moo; 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 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 regulations;AND,If the waste Is a treatment residue of a previously restricted hazartlous waste subject to the Land Disposal Y -YARDS <br /> Restrictions,I certify and warrant that the waste has beeniVe�fed in acxordan wI"t�the requirements of 40 CFR Part 268 and is no longer a M3 -CU131C METERS <br /> hazardous waste as defined by 40 CFR Part261. : 1 ( /� - ` % Y' -CUBIC YARDS <br /> ,MCL USSR�C w/Zm t'AV-D O -OTHER <br /> Generator Authorized Ag nt Name Signatu"re Shipment Date <br /> action a Transporter I complete <br /> Generatorcom letea-d; Brans RerPcom tete gU <br /> TRANSPORTER f TRANSPORTER II <br /> Name: ��' r (tAuk4tl -r'z n s:P?,ae h. Name: <br /> Address: .60i fa '6 1. Address: , <br /> (—'x , A 95011_ 5 <br /> Driver Name/Title: Z� j. Driver Name/rftle: <br /> PRINTfTYPE - PRINArYPE <br /> Phone No.: (y68) j •70go e. Truck No.: k. Phone No.: I. Truck No.: <br /> Vehicle License No./State: 77$/&49'•7/SIEOV" m.Vehicle license No./State: ' <br /> Acknowledgement of Receipt of Materials. Acknowledgement of Receipt of Materials. <br /> n i <br /> DrM re bY11 Date Drtver Si neWre Shi meet Date <br /> •��::¢„, ... - ,., desanetiori She completes eiJ c� <br /> Site Name: 1.�'f J l�lJlO o Nth� / V'W7F't�.L.- C. Phone No.: '7ZS '44 I- &AJ , <br /> Physical Address: d. Mailing Address "'tm� - 1` <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 /> I <br />