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r <br /> ..RL,US SPECIAL WASTE & % 3BESTOS MANIFEST <br /> If waste Is asbestos waste complete Sections I II III and 14 NO. Q`, I J <br /> II waste Is NQT asbestos waste complete only Sections 1 11 and III N J <br /> GENERATOR (Generator compieltau allot Section 11 <br /> .dneretor Name b Generating Location <br /> Address d Address <br /> I <br /> I <br /> Phone No f Phone No <br /> owner of the generating taclldy dMers from the generator provide <br /> Owner s Name h Owners Phone No <br /> TYPF <br /> BFI WASTE CODE I Containers OM METAL DRUM <br /> OF PLASTIC DRUM <br /> 8 BAG <br /> Descnpbon of Waste k uantily Onris No TYPE BA 6 MIL PLASTIC BAG <br /> or 0 <br /> + m m T TRUCK <br /> O OTHER WRAP <br /> GENERATOR S CERTIFICATION I hereby certify that the above named material is not a hazardous waste as defined by 40 CFR Pan 261 or UNITS <br /> any appdrable state law has been property described classified and oaCkaged and is in proper Condition for transportation according to P POUNDS <br /> appiicabie regulaeens ANO it the waste is a treatment residue of a previously restricted hazardous waste subject to the Land disposal Y YARDS <br /> ResirMitonS I Certlty and warrant that the waste has been treated in accordance wnh the requirements of 40 CFR Part 268 and is no longer a M CUBIC METERS <br /> hazardous waste as defined by 40 GFR Pan 261 Yl CUBIC YARDS <br /> I FM O OTHER 1 <br /> Generator Authorized Agent Name Signature Shipment Date <br /> Transporter[COmptete e'9 <br /> 36CYlot1 II TRANSPORTER Generator eemplete a-d Trans iter tf cam tete h-n) <br /> TRANSPORTER[ TRANSPORTER11 <br /> 1111 r ) I <br /> Name h Name <br /> Address + Address <br /> ! <br /> Driver Name(Title ) Onver Name/Title <br /> PRINTr TYPE PRINT17YPE <br /> Phone NO a Truck No k Phone No I Truck No <br /> 0License No rState e r - _.-�_.- _ m Vehicle License No/State <br /> wledgement of Receipt of Matenals Acknowledgement of Receipt of Materials <br /> –rn <br /> — <br /> Diner S nature Shi enj pale Driver Sr nature Shr mem Dale <br /> 3ectforlr III DESTINATION (Generator completes a-fill destination site completes e f) <br /> Site Name c Phone No <br /> Physical Address d Mailing Address <br /> Discrepancy Indication Space <br /> I hereby certify that the above named material has been accepted and to the best of my knowledge file foregoing is true and accurate <br /> I/ T <br /> Nblt.ol AuT4n16d Agent Slgnatern, R.cegt Det. <br /> Section TV ASBESTOS (Generator complete ed f g Operator completes e) <br /> Operator's Name b Operator's Phone No <br /> (Doeratol's Address <br /> Special Handling Instructions and additional mformahon <br />)PERATOA S CERTIFICATION I hereby declare that the convents of this consignment are fully and accurately described above by proper shipping name and are ciassidieu <br /> ricked marked and labeled and are rn all respects in proper Cond hon for transport by highway according to applicable International and government regulations <br /> �TT� <br /> Operators Name&Tole I l1on, LI E <br /> P n T,,i �ner..ror a ainn„n n r)�ic <br /> Ndme ann Address <br /> of Responsible Agency <br /> -nab* Non Inable Both 1.triable q,nonfnable <br /> ,nE 1 or Orals 10 he CDmbany eases Jac net „o^ o ti r ,oerv,sas IhO I3c0ty dr ng demnfishen 7r leirWafnd Jr e demnrtlion or renovat on operitroi of boli, <br /> 0 ONLY THROUGH HR CARCO CONTRACTQ 110 1^U!5 i <br /> �iq_F'r1P7F r ,at Tgifv <br />