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i <br /> NON-HAZARDOUS SPECVASTE & ASBESTOS MANIFEST <br /> Ifwaste is asbestos waste,complete Sections I it,III and IV No. 005971 <br /> It waste is NOT asbestos waste,complete onty Sections I i!and III <br /> 1 GENERATOR (Generator completes all of Section t) <br /> a Generator Name Cr'.EV RON- S fui1 RA LON b Generating Location CHEVRON 9-4275 <br /> c Address d Address —'9C 0 BES'TAMI`' HOLT, CROSS STREET PLYMOUT <br /> STOCKT011,, CA <br /> e Phone No I Phone No <br /> If owner of the generating facility differs from the generator,provide <br /> g Owner's Name h Owner s Phone No <br /> TYPE <br /> t BFI WASTE CODE 3 Containers DM-METAL DRUM <br /> DP -PLASTIC DRUM <br /> _ B -BAG <br /> PLASTI <br /> t Description of Waste _'ww ��'r Y It �� k Ouantd f tfn�ts No TYPE BA -8 MIL or WR PC BAG <br /> T -TRUCK <br /> I V1 -OTHER <br /> GENERATOR S CERTIFICATION I hereby cenify that the above named material is not a hazardous waste as defined by 40 CFR Part 261 or <br /> UNITS <br /> any applicable state law has been properly desenbed 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 restncted'hazardous waste subject to the land Disposal Y -YARDS <br /> Restrictions I certify and warrant that the waste has been Ireated li/%accordance wdrlho requirements of 40 CFR Part 268 and is no longer a M' -CUBIC METERS <br /> hazardous waste as defined by 40 CFR Part 261 / /f��j / 0 O -OTHER <br /> -CUBIC YARDS <br /> f l Jl 4/ � <br /> Generator Authorized Agent Name signatdre f Shipment Date <br /> r Trat,sfwrter I complete e� <br /> Section II TRA SPORTER (Generator complete a4T rte,R tete h-n <br /> TRANSPORTER I TRANSPORTER n <br /> aflame A IWLSTE }RANSFORTATION h Name <br /> b Address <br /> 1475 LI AGAS I Address <br /> SAN MARTIN. CA ! <br /> T- <br /> c Driver NametTitle + 1 t Driver Namefritle <br /> PRINVIFYPE <br /> PRINVIYTru <br /> PE <br /> I Truck NO <br /> d Phone No of Truck No k Phone No <br /> f Vehicle License NoJState <br /> m Vehicle License NoJState <br /> Acknowledgement of Receipt of Materials Acknowledgement of Receipt of Materials <br /> Dnvw 5 nature <br /> Shi anent Date Driver Signature <br /> Sh nt Date <br /> Section III DESTINATION (Generator completes a-d,destnaton site completes e-f) <br /> a Site Name i' r = c Phone No <br /> b Physical Address h 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 /> EL= <br /> # Receipt Date <br /> Name of Authorized Agent Signature <br /> Ion TV ASBESTOS (Generator comptete a-d,f g,Operator'completes a) <br /> 1111W <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 descnbed above by proper shipping name and are clas <br /> packed,marked,and labeled,and are in ata respects in proper condition for transport by highway according to applicable international and government regulations <br /> v I I I I <br />