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Y <br /> 1'AY <br /> UNIVE,PSAL ENVIRONMENTAL <br /> P.O. Isle <br /> BOX 996, BENICIA,CA 94510,(707)747-6699 <br /> NON-HAZARDOUS SPECIAL WASTE MANIFEST <br /> GENERATOR <br /> Generator Name Generating Location <br /> Address1� ' <br /> Address <br /> Phone No. -. L II .r;L, <br /> { Phone No. <br /> Containers Type <br /> Description of Waste Quanfit Units No. T pe D- Drum <br /> C-Carton <br /> a � 7Ll <br /> B - Bag <br /> m ❑ T -Truck <br /> EI= ❑ <br /> P -Pounds <br /> Y-Yards <br /> 0-Other <br /> I hereby certify that the above named material does not contain free liquid as defined by 40 CFR Part 260.10 or any applicable <br /> state'law, is not a hazardous waste as defined by 4MFR Part 261 or any applicable stateAaw, has b66n properly described, t. <br /> classified and package,,'d, andis in proper condition for'transportation according to applicable regulations. <br /> Generator Authorized Agent Name Signature Shipment Date <br /> TRANSPORTER <br /> Truck No. �' Phone No. <br /> Transporter Name r j ,M r'. Driver Name (Print) <br /> Address Vehicle License No./State <br /> Vehicle Certification <br /> I hereby certify that the above named material was picked up I hereby certify that the above named material was delivered with- <br /> at the generator site listed above. out incident to the destination listed below. <br /> a 'o f <br /> Driver Signature Shipment Date Driver Signature~ <br /> Delivery Date <br /> DESTINATION <br /> Site Name Phone No. , <br /> Address l I <br /> reby certify that the above named material has been accepted Arid to fhe best of..-rriy knowledge the for going is true and accurate. <br /> Name or Authorized Agent -Signature "' Receipt Date'' <br />