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l <br /> NON-HAZARDOUS SPECTA-CWASTE & ASBESTOS MANIFEST <br /> r <br /> If waste is asbestos waste,complete Sections 111 Ill and IV No, 005975 'o 5 9 7 <br /> ! If waste is NOT asbestos waste,complete only Sections 1 II and f[I 1 V �J <br /> n� : GENERATOR (Generator completes alt of Section I) <br /> a Generator Name C-iL\',C' . ikA� n,A„011 C 1/t�r`it, 9--4}/5 <br /> b Generating Location <br /> c Address d Address Vit - fit..` ='` Ittik.1 CROb �);1ti A-'_ r'.1 tot. <br /> e Phone No f Phone No <br /> If owner of the generating facility differs from the generator provide <br /> g Owners Name h Owner s Phone No <br /> _,. 1- TYPE <br /> r SFt WASTE CODE 4 r 5 i t 5 Q a U Containers DM-METAL DRUM <br /> DP PLASTIC DRUM <br /> I Description of Waste k Quantity Units No TYPE BA -6 I 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 taw 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 treatment residue ofe previously restripted hazardous waste subject to the Land Disposal Y -YARDS <br /> Restrictions I certify and warrant that the waste has been treated in accordance with tpe requirements of 40 CFR Part 268 and is no longer a M' -CUBIC MI=TERS <br /> hazardous waste a defined by 40 CFR Part 261 /,! /, <br /> zz��" <br /> Ya -CUBIC YARDS <br /> / } ,// O -OTHER <br /> Gonetalor Authorized A ent Name Si n lureg g � __._ Shipment Date <br /> Section H TRANSPORTER Generator coin lete a-d Transporter 1 complete e� <br /> P Tran er I]cam late h-n <br /> TRANSPORTER f TRANSPORTER11 <br /> 10 <br /> t1;�Ll,e+UTE 1RINSPORT- TION h Name <br /> b Address 31475 i,1, GAS AVEFVE i Address <br /> SAN 1 ARTIN, CA <br /> c Driver Namelritle l��r; ` -'^�� I Driver Name/Title - <br /> -PRINTITYPE1 l" PRINTITYPr= <br /> d Phone No fes~ `':,Je Truck No ���_ 'y k Phone No I Truck No <br /> f Vehicle License No/State V t - `�C _ m Vehicle License No/State <br /> Acknowledgement of Receipt of Matenals Acknowledgement of Receipt of Materials <br /> g t ` n <br /> Diner Si nature Sh ment Date I Driver S nature Sh ent Date <br /> Section III DESTINATION (Generator completes a-d,destination site completes e-f) <br /> a Site Name _31i 1 VjlS).) f.J. <br /> c Phone No <br /> b Physical Address '` \i SCO d Mailing Address <br /> e 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 /> Name of Authorized Agent Signature Receipt Date <br /> Sect on IV ASBESTOS (Generator complete a-d,f,g,Operator'completes e) <br /> (Mot's*Name b Operators'Phone No <br /> Operator's'Address <br /> J Special 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 /> packed,marked,and labeled and are in all respects in proper condition for transport by highway according to applicable international and government regulations <br />