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SPECIAL WASTE & ,tswsBESTOS MANIFEST <br /> If waste asbestos waste complete Sections I II Ill and Iv A{O� <br /> li waste is NOT asbestos waste complete only Sections 1 11 and II I N - <br /> g I GENERATOR (Generator compieles all of Section I) <br /> Generator Name c Generating Location - <br /> 5 <br /> r� <br /> Address o Address <br /> Phone NO <br /> I Phone No <br /> i _� <br /> I owner of the generating facility difiers from the generator provide <br /> Owners Name h Owner s Phone No <br /> TYPE <br /> BR WASTE CODE I Containers QM METAL DRUM <br /> DP PLASTIC DRUM I <br /> B BAG <br /> Description of Waste < IQuantity Units No TYPE BA 6 MIL PLASTIC BAG ' <br /> O <br /> r WRAP <br /> T TRUCK <br /> O OTHER <br /> GENERATOR S CERTIFICATION I nersoy cattily that the above named maienal s not a hazardous waste as defined by 40 CFR Pan 261 orIT <br /> any applicable state law has been properly described classified aro vacicaged and s n proper condition for transportation according to P POUNDS <br /> appl>cable regulations ANO if the waste is a treatment residue at A previously restricted hazardous waste subject to the Land Disposal Y YARDS <br /> Restrictions 1 certify and warrant that the waste has been treated n accordance with the regwremems of 40 CFR Pan 268 and is no longer a M' CUBIC METERS <br /> hazardous waste as dolmed by 40 GFR Pan 281 Y' CUBIC YARDS I <br /> O OTHER <br /> Generator Authorized Agent Names Signature T Shipment Date <br /> Section II TRANSPORTED (Generator complete a-d TransTranspootterrter[acocommplete latee-hgw} <br /> TRANSPORTERI TRANSPORTER It <br /> a Name I. L h Name <br /> c Address I Address <br /> c Driver Narne,,Mtle Driver NamwTme _ <br /> P4iNT TVPE PRINTaYPE <br /> NaaTruck Nd k Phone No I Truck No <br /> 0.13 <br /> le Licerse No/State m Vehicle License No/State <br /> Acknowledgement of Receipt of Materials Acknowledgement of Receipt of Materials <br /> FT= <br /> g n <br /> Driver 5 a1w. Shlemenl Date DfIVe SI nalura ShI ent Dale <br /> Section iii DESTINATION (Generator completes a d destination site completes e f) <br /> a Site Name c Phone No <br /> b Physical Address d Malting Address <br /> e Discrepancy Indication Space <br /> 1 hereby camiy that the above named material has Open accepted and to the test of my knowledge the foregoing is true and accurate <br /> 1 <br /> name of auinonreu agent 5 gnamte RepM'pale <br /> Section Iv ASBESTOS {Generator complete" t q Operator completes e) <br /> a Operators Name o Operators Phone No <br /> o Operators Address <br /> d Special Handling Instructions and additional,ntornrauon <br /> OPERATOR S CERTIFICATION I hereby yeciare hat'he cony is or r s consignment are I illy and accurately described aoc+e by proper shipring name and are c assn'Pri <br /> packed marked and labeed and are in ail respects n proper condition or transport by nign fay accorcing to applicable International and government regulallors _ <br /> p Ope alor s Name&T tie _— <br /> 1p ,r Still— <br /> P i i mr <br /> y,me and Address <br /> dt RPsponsiole AcencV <br /> 40,1 Ir 3o e Bu __ 'no _ 'oninabli, <br /> n i �e e � a r rr. r uFu I to l r, i i rI n <br /> tIPrS L- <br /> �� THROU r.Ess "'q [±1)CONO'_' O <br /> -+CLN Cr.. 1 r''N5P0RTL tJ '"'11=T�Iha <br />