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l NON-HAZARDOUS lb�CIAL WASTE & ASBESTOS MANIFES1 <br /> If waste is asbestos waste,complete Sections I 11,III and IV <br /> - <br /> If waste is NOT asbestos waste,complete only Sections 1 11 and III No. 005978 <br /> Section I GENERATOR (Generator completes all of Section 1) - <br /> a Generator Name CIi_E'''e0A. SA,\ P_-Vi0-X b Generating Location C,J1h\'1'0_ c4-14_/5 <br /> c Address d Address �` ` BELN_A_Klx� NC:L'_�-, CROSS <br /> S'2UC1,T- '. CA <br /> e Phone No I 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 L A i I i 3 Containers DM METAL DRUM <br /> 'd DP -PLASTIC DRUI1 <br /> Description of Waste B BAG <br /> k Quantic Units No TYPE BA 6 MIL PLASTIC <br /> or WRAP <br /> m TTRUCK <br /> O -OTHER <br /> GENERATOR S CERTIFICATfON 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 <br /> Restrictions 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 Ili/{' -CUBIC METER; <br /> hazardous waste as defined by 40 CFR Part 261 3 <br /> Y CUBIC YARDS <br /> r O -OTHER <br /> r �r <br /> Generator Authorized Agent Name Signature, ( Shipment Date <br /> y <br /> Section II TRANS ORTER rGenerator com late a d Transporter I complete ey <br /> l p Trans rter if complete h-n <br /> TRANSPORTERI TRANSPORTERII <br /> a Name ALLVA S o h T j-0,,S?Gr:`i'AiT=ON h Name <br /> b Address 12475 LL.AGAS AVF"t1T_7 i Address <br /> SAN MARTIN CA <br /> c Driver Name/Tltle r I Driver Name/Title <br /> PRIN <br /> d Phone No Truck <br /> `r PiiiNTrrYPE <br /> e TTruck No J k Phone No I Truck No <br /> f Vehicle License No/State .f ` <br /> m Vehicle License No <br /> JState <br /> Acknowledgement of Receipt of Materials Acknowledgerrpent of Receipt of Materials <br /> x9L 1 , 121 L <br /> ,v0 i "� l3 <br /> n <br /> Diner nature Shipment Date Dnver Si ature Shi mem Date <br /> I Section III `"y DESTINATION (Generator completes a-d destination site completes e-1) <br /> a Site Name ��' �'`' ( ' t�� <br /> c Phone No <br /> b Physical Address 4 "' ``' �A ,l J ��1;� ; <br /> 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 f f <br /> J <br /> Name of Authorized Agent Signature - Receipt pate <br /> Section IV ASBESTOS (Generator complete a-d,f,g Operator"completes e) <br /> a Operator's'Name b Operators`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 eta <br /> packed,marked and labeled,and are in all respects in proper condition for transport by highway according to applicable international and goveMment regulations <br /> e Operators'Name 8 Title T _ F-T-7—T-T <br />