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,AR"US SPECIAL WASTE A'—SBESTOS MANIFEST <br /> II waste Is asbestos waste complete Sections 1 It Ill and Iv "+ Z <br /> €t waste is NOT asbestos waste complete only Sections 1 11 and 111 No. ~`- <br /> / GENERATOR (Generatorcomp€etas all of Section I) <br /> .cor Name b Generating Location <br /> tt+11 ,t <br /> AddreSS �'S 1 d Address <br /> e Phone NO S I - f Phone No <br /> d owner of the generating facility drtfers from the generator provide <br /> g Owners Name h Owners Phone No <br /> TYPE <br /> BFI WASTE CODE Containers DM METAL DRUM <br /> DP PLASTIC DRUM <br /> B BAG <br /> M Description of Waste k QuantityJ a No TYPE BA fi MIL WRAP IC BAG <br /> orr WRAP <br /> T TRUCK <br /> O OTHER <br /> GENERATORS CERTIFICATION I hereby candy that the above named material is not a natardous waste as delined by 40 CFR Pan 261 or UNITS <br /> any applicable state law has been properly described classified and packaged and is in proper condition for transportation according to P POUNDS <br /> apphnabte regulations AND If the waste Is a treatment residue of a previously restricted hazardous waste subleCt to the Land Disposal Y YARDS <br /> Res(M ions I certify and warrant that the waste ties been Treated in accordance with the requirements or 40 CFR Pan 268 and i5 no longer a M' CUBIC METERS <br /> hazamous waste as defined by 40 CFR Pan 261 Y' CUBIC YARDS <br /> O OTHER <br /> Generator Authorized Agent Name $tgnature s 1,24Jtlpment Date <br /> Transporter <br /> Section II TRANSPORTER (Generator com1 Complete Ir-g <br /> plete.-d Trans rter II coin ate h n) <br /> TRANSPORTERI TRANSPORTERII <br /> I _ <br /> a Name h Name <br /> o Address I Address <br /> tit r w <br /> c Driver NamefTMder I Driver Nametritle <br /> PRINTnYPE PRr3TfrYPE <br /> d Phone No a Truck No k Phone No i Truck No <br /> I le LtCertse No/State m Vehicle License No/State <br /> owledgement of Receipt of Materials Acknowledgement of Receipt of Matenals <br /> g . _ n <br /> Dauer s sirI Shipm,ria bate 1 13—5 tare sh ant Oat. <br /> Sectfon M DESTINATION (Generator completes a-d destination site completes 19-11) <br /> bFI It+ -It)) IST- I <br /> a Site Name c Phone No <br /> it I 1 <br /> b Physical Address d Matting Address <br /> t Iz <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 /> f r <br /> Name of Authearsd Agent Signature Recwpi Oale <br /> Section IV ASBESTOS tGnrterator complete a-0 f g Operator completea e) <br /> a Operators Name b Operators Phone No <br /> c Operator s Address <br /> d Special Handling Instructions and additional information <br /> OPERATORS CERTIFICATION I hereby declare that the contents of INS consignment are tufty and accurately described 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 /> e Operators Name&Title L 1 I i 7F] <br /> I <br /> P­irryp. operamr s S,gnarure Oa e <br /> r Name and Address <br /> of Responsible Agency <br /> y 7 Friable L Non friable _ Both '.triable °r.nonlnaVe <br /> Operator rete s le the company whit,oNPS leases operates COMM s or supervises the faciilly being demolished or renovated or the demddion or ienoval on operation or eolh <br /> OR ONLr THROUGH BFI uARCO CONTRACT TRANSPORTER RETAIN 0 zso-rsoa ssf <br />