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l <br /> NON-HAZARDOUS SFEG4AL WASTE & ASBESTOS MANIFEST <br /> If waste is asbestos waste,complete Sections 1 11 111 ant 1V No. r O <br /> If waste is Q asbestos waste complete only Sections 1 II and III �1 <br /> 05979 <br /> etton I GENERATOR (Generator completes all of sear..f) <br /> NW <br /> a Generator Name Gly; b't SA'� f e� ��}l� b Generating Location CiaL VR0 ' °-4'15, <br /> c Address d Address 1 `� �3` li�ili� -40_',v . CROSS �>TRLFT <br /> SIL <br /> e Phone No f Phone No <br /> If owner of the generating facility differs from the generator provide <br /> g Owners Name h Owners Phone No V <br /> TYPE <br /> BF!WASTE CODE , ) } 2 J L a j ; i, Containers DM-METAL DRUM <br /> DP -PLASTIC DRUM <br /> B BAG <br /> I Descrtplion of Waste k uantity Units No TYPE BA 6 MIL PLASTIC E <br /> or WRAP <br /> G T TRUCK <br /> ( ! O -OTHER <br /> GENERATOR S CERTIFICATION !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 oondiuon for transportation according to P -POUNDS <br /> applicable regulations AND of 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 agcordaace with he repinrements of 40 CFR Part 268 and is no longer a M' -CUBIC METERS <br /> hazardous waste as defined b 40 CFR Part 261 Y' -CUBIC YARDS <br /> f Y /j; <br /> Generator Authorized Agent Name Signature Shipment Date <br /> Section H TRANSPORTER (Generator complete a-d Transporter 1 complete eg <br /> i P Fran iter Il cont lete h-n <br /> TRANSPORTERI TRANSPORTERII <br /> i <br /> ame A,,,11IASTv, TR.ANSP0n!PTJ0N h Name <br /> b Address 1,475 LLAGAS AVENUE i Address <br /> SAN MARTIN. CA � <br /> c DriverName/Tille Zvi .., o 4 `2 _,_ 1 DriverName/Title ' <br /> PRI7 <br /> 7 PRINTfrYPE <br /> d Phone No a— __ S�: C� a Truck No [�✓ k Phone No I Truck No <br /> r^ — <br /> f Vehicle License No/State 7 C � I � m Vehicle License NoJState <br /> Acknowledgement of Receipt of Materials Acknowledgement of Receipt of Materials <br /> 1 / A/ <br /> g <br /> n <br /> Driver Signature Shipment Date Driver Signature Shiprneril Date <br /> Section III DESTINATION (Generator completes a-d destination site completes e-f) <br /> a Site Name 6F1 VA;C O RD• c Phone No <br /> b Physical Address 40G AI 1q. VASC O I Dii <br /> d Mailing Address <br /> __V1"< 'O:F , Cl, <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 /> Section IV ASBESTOS (Generator complete a-d,f,g,Operator'completes e) <br /> Operatoes*Name b Operators` Phone No <br /> c Operator's"Address <br /> d Special Handing 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 clas <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 /> e Operator's'Name S Title <br /> f�f` <br />