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CJ <br /> NON-HAZARDOUS SPECIAL WASTE & ASBESTOS MANIFEST <br /> If waste I asbestos waste,complete Sections I It,III and IV <br /> If waste tg NQI asbestos waste,complete only Sections 1 It and III No. 003758 <br /> tion I ' 'GENERATOR (Generator completes all of Section 1) Q <br /> a Generator Name S�1`� Generating Location CAeV nth ! 7T <br /> c Address d Address Zd d 9 ll.ei%t 1 C&p,r_x' <br /> e Phone No f Phone No <br /> If owner of the generating facility differs from the generator,provide <br /> g Owners Name <br /> h Owners Phone No <br /> i BFI WASTE CODE "/ TYPE <br /> J Containers DM-METAL DRUM <br /> DP -PLASTIC DRUM <br /> I Description of WasteB -SAG <br /> k Quantit Units No TYPE eA -6 MIL PLASTIC BA <br /> or <br /> m m O -OTHER WRAP <br /> GENERATOR S CERTIFICATION f 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 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 requirements of 40 CFR Part 269 and is no longer a M' -CUBIC METERS <br /> hazardous waste as defined by 40 CFR Part 261 Ya -CUBIC YARDS <br /> O -OTHER <br /> Generator Authorized Agent Name Signature Shipment Date <br /> Section II TRANSPORTER /Generator late a-d-'Transporter I complete e-g <br /> t comp Transporter 11 complete h-n j <br /> TRANSPORTERI TRANSPORTERII <br /> 14&e ✓f3� -Z niif tt Name t <br /> b Address <br /> r Address <br /> c Driver Name/Trtle _ _ f �---- I Driver Name/Trtle <br /> PRlnrrmPE /` <br /> d Phone No 06- e Truck NoPRINTIIYPE <br /> k Phone No I Truck No <br /> 1 Vehicle License No/State m Vehicle License No.IState <br /> Ackno l dgement 9� tot of Materials Acknowledgement of Receipt of Materials <br /> It 12-1010M in I <br /> Dmrer S' nature Shipawnt Date Diner Si azure Shi ment Date <br /> Section III DESTINATION (Generator completes a-d destination site completes e-1) <br /> a Site Name c Phone No <br /> b Physical Address 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 Authonzed Agent Signature Receipt Date <br /> segan N ASBESTOS (Generator complete a-d f g,Operator completes e) <br /> a tors`Name b Operator's`Phone No <br /> c Operator's'Address <br /> J Special Handling Instructions and additional information t <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 classrfiec <br />-jacked marked,and labeled,and are in all respects in proper condition for transport by highway according to applicable international and government regulations <br />