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-,riE-,US SPECIAL WASTE A _ .SBESTOS MANIFEST <br /> I1 waste is asbestos waste romplete Sections 1 11 1V and IV w'O- Y <br /> 6 If waste is NOT asbestos waste cemplete only Sections I II and I I I '�l ` <br /> GENERATOR (Generator completes all of Section 11 <br /> Oeralor Name' b Generating Location <br /> c Address d Address <br /> a Phone No f Phone No <br /> it owner of the generating facility differs from the generator Orovlde <br /> g Owners Name n Owner s Phone No _ <br /> f~T� 1 TYPE <br /> BFI WASTE CODE L I I i I I I Containers DM METAL DRUM <br /> M <br /> LLL--JLL--LLLJJJ DP PLASTIC DRUM <br /> B RAG <br /> Deserlptlon of Waste k Quantity ,lniis No TYPE BA 6 MIL PLASTIC HAG <br /> 11 0] m O OTHER T TRUCK <br /> WRAP <br /> GENERATORS GERTIFECATION I hereby certify that the above named malenal is nor a hazardoU5 waste as defined by 40 CFR Pan 26,or UNITS <br /> any applicable state law has peen property described Gass I ea dnu paux'igeo and is in proper condition for transportation according to P POUNDS <br /> apphn8ble regk ions AND If the waste is a treatment residue of a previously restricted hazardous waste subject to the Land Disposal Y YARDS <br /> Restnations I certify and warrant that the waste has been treated in accordance wnh the reoueemenis Of 40 CFR Part 268 and a no longer a M' CU131C METERS <br /> hazardous waste as defined by 40 CFR Part 261 Y'i CUBIC YARDS <br /> O OTHER <br /> Generator Authonzed Agent Name T Srt�ture _ ~ Shipment Date <br /> Section II Transposer!complete e g <br /> TRANSPORTER (Genefator complete a-d Trans iter tl cam Iete h n <br /> TRANSPORTER( TRANSPORTER (( <br /> a Name h Name <br /> to Address I Address <br /> c Dnver NamerTitle I Driver NamerTdle <br /> PRINI-YPF PgINTTYPE <br /> 7 Phone No e Truck No x Phone No I Truck No <br /> Ie License No Stator m Vehicle License No 1S late <br /> owleagement of Receipt of Materials � A� Acknowledgement of Receipt of Matenats <br /> 9 L I n IELTT71 <br /> 9r ver S naive phi mei Date I Dnvrr Si nawre Shipment date <br /> Section [[i DESTINATION (Generator completes a d destination site completes e I) <br /> a Site Name c Phone No <br /> b Physical Address d Mailing Address <br /> e Discrepancy Indication Space <br /> I hereby cenlfy that the above named material has been accepted and to the best of my knowledge the foregoing is true and accurate <br /> 1 <br /> Name a!Autrwnirfp Agent S,Q—,u n Receipt Dale <br /> Section IV ASBESTOS (Generatorr complete a d r g Operator completes a) <br /> a Operator s Name b Operators Phone No <br /> Operators Address <br /> a Special Handling instructions and addrtionaV nformallion <br /> OPERATOR S CER77FJCATION I hereby declare that the cortents or[his consignment are fully and accurately described above by proper snipping name and are classilieo <br /> vaCked marked and labeled and are in ail resoect5 In proper cpIdibpn for transition by highway accordinq to applicable international and government regulations <br /> 7peralcrs Name 8 Ttie <br /> ..+ �• � )P i� 7 1^TI �sir. <br /> Name and Address <br /> Resoorssiole Agency <br /> = able =No, �b a Ro, _ iabie on ria5ie <br /> is � , tit , ,rn i i i o nidi w i i i i i i <br /> -� -HaoL•,.. tF ..a-']CU^,.WaC- —s�4rI�AnF}T�r� '�r_.-,i Q n <br />