ARCHIVED REPORTS XR0000359 - Laserfiche WebLink

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If waste is asbestos waste,complete Sections I II Ili and IV If waste is Q asbestos waster,complete only Sections I II and III No. 096400 Section I GENERATOR (Generator completes all of Section I) OneratorName Cti �i t t!` �.� - b Generating Location c Address r- l� d Address j"- kA 16 v%,%A Pf e Phone No f Phone No If owner of the generating facility differs from the generator provide g Owner's Name h Owner's Phone No TYPE: i BFI WASTE CODE L j # Sl� Containers DM-METAL DRUM DP -PLASTIC DRUM r' B -BAG I Description of Waste > 1 ;n k Quanta Units No TYPE BA -6 MIL PLASTIC eA or Il. 1A a �, O -OTHER WRAP 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 any applicable state law has been property described classified and packaged and is in proper condition for transportation according to P -POUNDS applicable regulations AND,if the waste is a treatment residue of a previously restricted hazardous waste subject to the Land Disposal Y YARDS Resinctions I certify and warrant that the waste has been treated in accordance with the requirements of 40 CFR Part 268 and is no longer a M' -CUBIC METERS hazardous waste as defined by 40 CFR Part 261 Y3 -CUBIC YARDS 1 Z 1.l'' ;.`--t �j O OTHER Generator Authorized Agent Name Signature Shipment Date Section II c TRANSPORTER Generator corn tete a-d Transporter I complete h < R Tia iter u oom late h-n i TRANSPORTER I TRANSPORTER II a Name !—' ' :, �� `T,o h Name ' ress i Address - t-� c Driver Namelritle o t f� [,P 4 _ .... I Driver Name -- PRINT17PE PRINTITYPI= d Phone No a Truck No �r k Phone No I Truck No f Vehicle License No/State '~ ';� �,, m Vehicle/License No/State Acknowledgement of Receipt of Matenals Acknowledgement of Receipt of Materials 1 - Dnver S nature Shipment Date I Driver Si nature Shipment Date Section III r DESTINATION (Generator completes a-d destination site completes e-11) ° a Site Name c Phone No b Physical Address •- _ r 4e, VN--c d Marling Address e Discrepancy Indication Space hereby certify that the above named material has been accepted and to the best of my knowledge the foregoing is true and accurate f �FY Name of Authonzed Agent Signature Reoeipt Date Section IV ASBESTOS (Generator complete a-d f,g,operator`completes e) a Operator's`Name b Operator's'Phone No porator's`Address d Special Handling Instructions and additional information OPERATOR'S CERTIFICATION 1 hereby declare that the contents of this consignment are fully and accurately described above by proper shipping name and are classih packed,marked and labeled and are in all respects in proper condition for transport by highway according to applicable international and government regulations e Operator's'Name&Title Pnnt/Type Operator's Signature Date f Name and Address