ARCHIVED REPORTS XR0003447 - Laserfiche WebLink

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NON-HAZARDOUS SPECIAL WASTE & ASBESTOS MANIFEST iT If waste is asbestos waste complete Sections t 11 111 and 1V No. 907914 If waste IS NDI asbestos waste Complete only Sections 1 11 and[II Section I GENERATOR fconerat�rowt,pteteaauotseepen� , ;, a Generator Name ol) ",)w4 rine I b Generating Local .a r't At = - Address crA f'tr?1^ lupi �{TtLt).7 C 1 ee) +u re)) d Address _7 01; Poll r i 4 1 II. ')Stop T'� .7'i,-2113r ' Phone No -t Z 1 f Phone No .' f owner of the generating facility differs from the generator provide Owners Name I- it 1))t ' h Owners Phone No >tmV ti> f r. SFl WASTE CODE m l 1 > + n , _ TYPE Containers OM-METAL DRUM DP PLASTIC DRUM Description of Waste "Ir 11 xznt ts4ue Cil} B BAG k Quant UntsNo TYPE BA 6 MIL PLASTIC BAG LEL tl ao 1' 1 MT T TRUCK 0 OTHERr WRAP GENERATOR$CERTIFICATION I hereby certify that the above named material Is not a hazardous waste as defined by 40 CFR Part 261 or , any appllCable state law has bean properly described classified and paCkaged and is In proper condition for transportation according to UNIT P POUND$ applicable regulabons AND it the waste Is a treatment residue of a previously restricted hazardous waste subject to the Land Disposal Y YARDS ABstriCtjons )certify and warrant that the waste has been treated in accordance with the requirements of 40 CFR Part 268 and Is no longer a M' CUBIC METERS hazardous waste as defined by 40 CFR Pan 261 t t r f)E t t t i ! 2 I:y i rt i R ` Y} CUBIC YARDS r-1 fit h_ '� Y i I O -OTHER Gan eretor AutttOaZed Agent Name a,e f ` + Shipment Data 4��C-� p�' LntFr iectlDn it TRANSPORTEReeneratgrce etee-dt T,`a�n�,pO`1°i�m i 1°se r t x`� ` " -7 TRANSPORTER I TRANSPORTER N I I s i rf I Ti itr Ir Il 111r Name h Name L I1 _'1 Address I Address loameMtle 15P .'1+ ' {1;:,K I Dhver NarnaMtfe -- Phone No 1 is i I—(;8 X41 PRINTIrype QCT / PRtNT/fVPE ne Truck No f k Phone No I Truck No Vehicle License NoJState )(q M Vehicle License NoJState Acknowledgement of Receipt of Materials Acknowledgement of Receipt of Materials n purer 5 Wre shiomonr pate piiver 8 [un ta" ec 1Dn IA DESTINATION (Generator completes a-d destMation si @ c=peates e•f) t i y l t � ! Ltitlf: fii Site Name c Phone No O t 01 14--0191 Physical Address 1`iti) `iij t.r ' ,,.,r t Rtittl d Mailing Address 1001 Not tb Lasco haled I l - tktutt Liketmutr' ;A 93i'SO I Discrepancy Indication Space I hereby certify that the above named material has been accepted and to the best of my knowledge the foregoing is true and accurate = ' ! 9 iOB-- 2002 ba Nu++amnua,an:.aAgent saoi;.Wre Reelloare P0= Ot]-20494 ''w:+T-_ action i� � -�t« A�3BESTOW_(Generatoreompletaadt�'gvgp�rstot"Wmda �- Operator's Name b Operators Phone No Operator s Address Special Handling Instructions and additional information ERATOA S CERTIFMATION I hereby declare that the contents of this consignment are fully and accurately described above by proper shipping name and are classilfed ked marked and labeled and are in all respects in proper conditon for trail by highway aMording to applicable international and government regulationS Operators Name 8 Title FT PnnVType Ocerators Signature Name and Address pare 31 Responsible Agency ble L_ Non friable ❑ Both °,friable %nonfnable Operator refers to the company which owns leases operates controls Lr superv,ses the facility being aemolmhe l or renovated or the demolition or renovation operation or both SAIOER ON(Y THRCR IrH RcI f I IA Rrn rONTRArT --