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l NON-HAZARDOUS SPECIAL-WASTE & ASBESTOS MANIFEST <br /> Itwaste is asbestos waste,complete Sections 1 II III and IV Nb. Q 4 1 9 0 9 <br /> It waste is NQT asbestos waste,comptefe only Sections 1 II and III Itl V 1 V <br /> iB I GENERATOR (Generator completes all of Section 1) I <br /> Generator Name r` i� ' �.�- b Generating Location <br /> _ r <br /> ? <br /> Address d Address <br /> Phone No f Phone No <br /> owner of the generating facility differs from the generator,provide <br /> Owner s Name In Owner s Phone No <br /> TYPE <br /> BFI WASTE CODE / r ? % Containers DM-METAL DRUM <br /> faP -PLASTIC DRUM <br /> B -BAG <br /> _ <br /> Description of Waste 1 1 f / ` ' k Ouantit units No TYPE BA -6 MIL PLASTIC BAG <br /> m m or WRAP <br /> F1-1 -1 1 1 [] T -TRUCK {i <br /> O -OTHER <br /> GENERATORS 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 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 I <br /> Restrictions I certdy and warrant that the waste has been treated in a&ordance withAhe requirements of 40 CFR Part 268 and is no longer a M9 -CUBIC METERS <br /> hazardous waste as defined by 40 CFR Part 261 Y3 -CUBIC YARDS <br /> O -OTHER <br /> Generator Authorized Agent Name Signatufe / Shipment Date <br /> I <br /> Section H TRANgPORTEFJ Generator oomplete a-d, Tr` W','er l Mt#e!e hgn <br /> TRANSPORTER I ter- �f TRANSPORTER H <br /> ; .,Y r �C / C.��� h Name <br /> i Address I r f — ��t- � � � Address <br /> 14 4 <br /> Driver Name/Title 1 F� C y Dnver Name�tfe <br /> I �r PRINT(rYPE PRINT/TYPE <br /> i Phone No % e Truck NoP114</ k Phone No I Truck No <br /> Vehicle License No/State _ /� �% m Vehicle License No/State <br /> Ackno`dedgement of,'Receipt of Materials Acknowledgement of Receipt of Materials <br /> I -r G r <br /> Driver Si nature Shipment Date prner Signature shipment[?ate <br /> Section III DESTINATION (Generator completes a-d destinatton site completes e-f) ` <br /> 3 Site Name c Phone No <br /> Physical Address d Mailing Address <br /> 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 /> FT <br /> f <br /> Name of Authorized Agent Signature Receipt Date <br /> Section IV ASBESTOS (Generator complete a-d,f,g,operator'completes e) <br /> a 9tors*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 classdiec <br /> packed marked and labeled and are in all respects in proper condition for transport by highway accordsng to applicable international and government regulations <br /> e Operator's"Name&Title <br />