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_LARLAUS SPECIAL WASTE &'--SBESTOS MANIFEST <br /> 11 waste Is asbestos waste complete Sections 1 11 Ill and 1V No. <br /> '307909 <br /> i If waste is 1=asbestos waste complete only Sections 1 It and Ill ��i <br /> GENERATOR (Generator completes all of Section 11 <br /> • r earl 'om aril C 11 - <br /> Generator Name y P 0 Generating Location <br /> 1�+ t'3jt1gasl}iti �2uts� it - - <br /> Address d Address <br /> t Ila <br /> Haus t tit T' - - - <br /> Phone No 47 1-1' 1 f Phone No <br /> owner of the generating facility differs from the generator provide <br /> Owner's Name <br /> F, ,c o r Jat}„111% L 1 h Owners Phone No rm� <br /> ' i : U 1 i Containers DM METAL DRUM <br /> BFI WASTE CODE m DP PLASTIC DRUM <br /> B BAG <br /> Description of Waste h+r w t 1 r++- k Ouanti I r a BA fi MIL PLASTIC BAG <br /> or WRAP <br /> TFT] TRUCK O OTHER <br /> GENERATOR 5 CERTIFICATION I hereby certify that the above named material,s not a hazardous waste as defined by 40 CFR Pan 261 or UNITS <br /> any applicable state faw has been properly descnoed classified and packaged and is im proper condition tof transportation according to P POUNDS <br /> applicable regulations AND it the waste Is a treatment residue of a previously restricted hazardous waste sublect to the Land Disposal Y YARDS <br /> Restrictions I certify and warrant that me waste has been treated in accordance with the requirements of 40 CFR Part 266 and a no longer a M' CUBIC METERS <br /> hazardous waste as defined by 40 CFA Part 261 1, t t F Y' CUBIC YARDS <br /> O OTHER <br /> Generator Auttlonzed Agent N e SipRa[cue r cr Shipment Date <br /> Lrlinp �3ectonII TRANSPORTER Generator complete a-d. Taer complete <br /> TRANSPORTERI TRANSPORTER11 <br /> r Name Ell Ilai d Ti u- kine =tit h Name <br /> s Address P u Do _t cs i Address <br /> B%I alis CA ` 1-1 1 <br /> OrrverNamelTitle I Driver NameMtle <br /> PRINYIY'IPE PRINT/TYPE <br /> J Phone No a Truck No k Phone No I Truck No <br /> e Ucense NoJState m Vehicle License No/Slate <br /> owledgement of Receipt of Materials Acknowledgement of Receipt of Materials <br /> g - n <br /> Onver afore 5hiemont pate 1 0nvar Sigmtum ShipmoiiilL Dare <br /> Section III DESTLNATION (Generator oompletes a d destination site completes ea) <br /> f3i'r, ',timet Etd Lutttit. li 'tri tk- <br /> a Sole Name c Phone No <br /> kf1f13 Irl rF �e 1 1irvl ` ,t 1-h ' 't „t' <br /> b Physical Address d Mailing Address <br /> Lltl'[alUtia , el;^ � Li -c 4t i , 1I- , <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 /> fS,gneaue Receipt Date <br /> Name at Aua,oitzed A17W++ <br /> Section rV ASBESTOS (Generator complete a-d I g Operator completes 0) <br /> a Operator's Name b Operators Phone No <br /> c Operator's Address <br /> d Special Handling Instructions and addlhonai information <br /> OPERATOR'S CERTIFICATION I hereby declare that the contents of this consignment are fully and accurately descnbed above by proper shipping name and are classified <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 /> II L, <br /> e Operators Name&Title <br /> PnnV7ype OGeraiW s Signature <br /> f Name and Adctess <br /> of Respons*� Agency <br /> g ❑ Fnablig 'Er 4n friable [] Both °°friable %noninabie <br /> geraior refers to the Company winch owns leases operates controls or supervises me facihiy being dempnsned or renova ed or the demolition or renovation o0grat,on or oath <br /> ER ONLY THROUGH 6FI 1 UARCO CONTRACT © zso-7208 5 9J <br /> TRANSPOFITER RETAIN <br />