Laserfiche WebLink
S <br /> I <br /> i NQN-HAZARDOUS SPECIAL WASTE & ASBESTOS MANIFEST <br /> 1 <br /> V waste is asbestos waste,complete Sections 1 11 III and IV n <br /> e If waste is NOT asbestos waste,complete only Sections I 11 and III No. 0 <br /> 41910 <br /> Section I GENERATOR (Generator completes all of Section I) <br /> a Generator Name Generating Location .� f f z r!'r 2�' l <br /> c Address <br /> d Address <br /> e Phone No f Phone No <br /> 11 owner of the generating facility differs from the generator provide <br /> g Owner's Name h Owners Phone No <br /> TYPE <br /> i BFf WASTE CODE �� ` r , �* —, (� Containers DM-METAL DRUM <br /> DP -PLASTIC DRUM <br /> B BAG <br /> I Description of Waste t / �� k Quantity Units No TYPE BA -6 MIL PLASTIC BF <br /> or <br /> T -TRUCK WRAP <br /> 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,it the waste is a treatment residue of a previously restricted hazardous waste subject to the Land Disposal Y -YARDS <br /> Restrictions I certify and warrant that the waste has been treated in accordance with the reqtarbments 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 -OTHER <br /> c- <br /> Generator Authorized Agent Name Signature / Shipment Date <br /> 11 1 <br /> Section II TRANSPORTER Gane torcompiete at1 Tia spordter iI oom lemic hM <br /> L TRA�JSiPORTER I_ TRANSPORTER II <br /> a Name t r� , 1 f r f h Name <br /> b Address t -7 ^� 7 i Address <br /> r, <br /> c Driver Namelfttle _ f .- �!I .� .f _ 1 Dnver Namelfitle <br /> PRINTlrYPE <br /> PRINT/TYPE <br /> d Phone Nps 4 f r ?! " .`��/ e Truck No `'C_ f Ic Phone No I Truck No <br /> i <br /> f Vehicle License No/State l �' i m Vehicle License No/State <br /> Acknowledgement of Receipt of Materials Acknowledgement of Receipt of Materials <br /> n <br /> Driver S ature S.N m Date I Driver Signature shipment Date <br /> Section III DESTINATION (Generator completes a-d destination site completes a-f) <br /> a Site Name r c Phone No <br /> b �Physical Address c- �� irr <br /> Y _ _ � ' ✓+'i d Hiding 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 /> f I JA I:—M <br /> Name of Authorized Agent Signature Rem pt Date <br /> i <br /> Won IV ASBESTOS (Generator complete a-d,f,g Operator'completes e) <br /> a Operator's`Name b Operator's'Phone No <br /> c Operator's'Address <br /> d 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 classii <br /> packed marked and labeled and are in all respects in Droner condition for trancnort by hfnhwav nrrnrfirnn fn annl,rah1P intnrnphnnpt ani+­­nr,,, 1 1'.....r <br />