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NON-HAZARDOUS SPECIAL WASTE & ASBE�TOS MANIFEST <br /> If waste is asbestos waste,complete Sections I II,III and IV w' A 7 <br /> If waste is NOT asbestos waste,complete only Sections I II and III . ,V 0' `Ff d <br /> S Ofl I - GENERATOR {Generator completes all of Section]) <br /> a Generator Name U ��U N ' r i Kf3 4`1 l��F t b Generating Location C-:-�e J Roti 9` q , _- <br /> c Address d Address I C-4-) ' 4 Y )t <br /> e Phone No f 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 /> i BFI WASTE CODE "-I �J �J _ () 6 < f Containers DM-METAL DRUM <br /> DP -PLASTIC DRUM <br /> B -BAG <br /> f Description of Waste k uantity Units No TYPE BA -6 MIL PLASTIC BAG <br /> or <br /> m m7 TRUCK <br /> O OTHER WRAP <br /> GENERATOR S CERTIFICATION I hereby certify that the above named material is not a tiazardous waste as defined by 40 CFR Part 261 or UNITS <br /> any applicable state law 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 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 acoordance with the requirements of 40 CFR Part 268 and is no longer a M3 -CUBIC METERS <br /> hazardous waste as defined by 40 CFR Part 261 ti Ya CUBIC YARDS <br /> 0 -OTHER <br /> Generator Authorized Agent Name Signature Shipment Date <br /> Section II TRANSPORTER (Generator icompi�ea-d Tia'r'tteruffepIIp'&hart <br /> r TRANSPORTER I ! d� TRANSPORTER H <br /> a ee ! f � S � ;`C� �l�1 f !r h Name <br /> b Address L 54km',4kJ- <br /> C4,r Address e <br /> c Driver Name[Tdie ! Ism ti i Ji,� — — - f -Driver Namerritle- <br /> .� PRINTfrYPE f PRINTfrYPE <br /> d Phone No 4 f � J e Truck No 5 / 1 k Phone No I Truck No <br /> f Vehicle License No/State r�"� �C3 m Vehicle License NoJState <br /> Acknowledgement of Retelpt of Materials Acknowledgement of Receipt of Materials <br /> ) 'A t t <br /> g FY i -• II`�L f r n M1 <br /> Ddvar Signature �� shipment Date Diner Signature Sh9rnent Date <br /> Section III DESTINATIO (Generator completes ail destihatwn site completes e-f} <br /> 7" <br /> a Site Name f f `� � �' ` c Phone No <br /> a <br /> b Physical Address _ ! j �� r d Mailing Address <br /> e Discrepancy 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 /> f <br /> Name of Authaued Agent Signature Receipt Date <br /> n IV ASBESTOS (Generator complete a-d,f,g,operator"completes e) <br /> 14 <br /> a perator's'Name b Operator's'Phone No <br /> c Operator's`Address <br /> d Special Handling Instructions and additional information <br /> OPERATOR'S Ct_RTIFICATION I Hereby declare that the contents of this consignment are fully and accurately described above by proper shipping name and are classifie <br /> packed,marked,and labeled,and are in all respects in proper condition for transport by highway according to applicable int6mationat and government regulations <br />