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i NON-HAZARDOUS SPECIAL WASTE & ASBESTOS MANIFEST <br /> I If waste is asbestos waste complete Sections I II III and IV 005970 5 d <br /> f If waste is NOT asbestos waste complete only Sections 1 If anNo. <br /> d III 5 <br /> (ction` GENERATOR (Generator completes all of Section[) <br /> a Generator Name CrL L<- ', r,k.` b Generating Location "-ILV 9-42-/5 <br /> c Address d Address a(^� '?�,:Jk:sHOii, CsiOSz:, STKEET ?_' Yl, <br /> e Phone No f Phone No <br /> It owner of the generating facility differs from the generator provide ' <br /> g Owners Name h Owner s Phone No <br /> TYPE <br /> i BFI WASTE CODE ,� F M, Containers DM-METAL DRUM <br /> DP -PLASTIC DRUM <br /> B BAG <br /> 1 Description of Waste k OU ntity units No TYPE BA 6 MIL PLASTIC E <br /> or WRAP <br /> T TRUCK <br /> m m O OTHER <br /> GENERATORS CERTIFICATION I hereby certify that the above named material is not a hazardous waste as defined by 40 CFR Part 264 or UNIT <br /> any applicable state (aw 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 accordance with the rggwrements of 40 CFR Part 268 and is no longer a M' CUBIC METERS <br /> hazardous waste as defined by 40 CFR Part 261 Y3 -CUBIC YARDS <br /> O -OTHER <br /> Generator Authorized Agent Name Sig attire r Shipment Date <br /> l " Transporter I oomplete s g <br /> i Section II TRANSPORTER (Generator complete a-d, Trans orter II coin Tete h n } <br /> TRANSPORTER ] TRANSPORTER N <br /> OName ALLWASTE Tk'ANIL,PORTAT SCI. hj Name <br /> * <br /> + b Address 12475 LIAGAS AVE] uj7 I Address <br /> SAN TIAs. •I N, tvlN , 1; � <br /> A{ <br /> J f/ I <br /> c Driver Name/Title c r t I Driver Name/Title <br /> PRINTrFYPE ; PRINT'TYPE <br /> d Phone No r, e Truck No k Phone No r I Truck No <br /> I Vehicle License NoJState 7 m Vehicle License No/State <br /> } Ackne <br /> 7V J , <br /> gf Receip�f Materials Acknowledgen4ent of Receipt of Materials <br /> , <br /> Drroer S attire Sh ment Date Driver Signature Slipment Date <br /> Section III DESTINATION (Generator completes a-d,destination site completes e4) <br /> a Site Name B3`J� VA:(1 G n:, c Phone No <br /> b Physical Address d Mailing Address <br /> I <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 /> Name of Authorized Agent Signature Receipt Date <br /> jAftaction IV ASBESTOS gGenerator complete a-d,f,g Operator"completes e) <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 described above by proper shipping name and are cla <br /> packed,marked,and labeled,and are in all respects in proper condition for transport by highway according to applicable international and government regulations <br />