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SPECIAL WASTE & _SBESTOS MANIFEST <br /> If waste is asbestos waste complete Sections 1 11 Ill and[V No. D f'1 r]F� <br /> If waste Is(yQlasbestas waste complete only Sections E I[and Iii i`� `7 V L <br /> GENERATOR [Generetar comptrtn ell of S.ctlon I) <br /> I Wot Name jr, ,rtt ur+{r Xtra S b Generating Location <br /> '1J6n31Fi+;tsR �yH�,J 1l SII u1b „ ,- <br /> Address d Address <br /> tluustoil '1't 77252-21 { = kt,u <br /> a Phone No 1710; °j{, 7 r`'1 f Phone No <br /> If owner of the generating faality,differs from the generator provide <br /> g Owner's Name E"ul) C riaulaf S h Owner's Phone No n'' <br /> TYPE <br /> i BFI WASTE CODE rt Containers DM METAL DRUM <br /> DP PLASTIC DRUM <br /> B BAG <br /> 11�'eS<Ii a- l l <br /> I Description of Waste No, K Out TYPE BA 6 MIL PLASTIC BAG <br /> or WRAP <br /> E [1] T TRUCK <br /> O OTHER <br /> GENERATOR S CERTIFICATION I hereby certify that the above named material is not a narardous waste as defined by 40 CFR Pad 261 or UNITS <br /> any applicable state law has been property described classified and packaged and is in proper condition for transportation aeeording to P POUNDS <br /> applicable regulations AND if the waste is a treatment residue of a previously restricted hazardous waste subject to the Lard Disposal Y YARDS <br /> Restrictions I 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 <br /> hazardous waste as defined by 40 CFR Part 261 d l r l;s f-,, ( 6I Y' CUBIC YARDS <br /> O OTHER <br /> lrlif.t' rF/LsL / 1 <br /> Generator Authorized A Name ,Signature .. Shipment Data <br /> Section 11 - TRANSPORTER Generator rblltplate a-d- Tan r,,comet n fi <br /> TRANSPORTERI TRANSPORTERII <br /> D111ard T.utking Iur <br /> a Name h Name <br /> P 0 5u, 21R <br /> b Address i Address <br /> Byt 0'1 I,, 9.1 Ss I <br /> c Driver Name/Title ,m r +.�/. r _ _ [ Driver Name/Tstle <br /> S ll i5't 1-i,4ti0 PR1NT/7YPe PRINTrrYaE <br /> d Phone No a Truck No ^;n.'> k Phone No I Truck No <br /> f Cle License No,/State S . 7 / /!T 7f m Vehicle License NOJState <br /> owledgement of Receipt of Mate els Acknowledgement of Receipt of Materials <br /> M1 <br /> orrver s M Shipritent bate Dinar shipment Oar. <br /> Section III DESTINATION (Genera[«completes as deanallan site computes a-f) <br /> BFI ,u (u Rd L trit'iit (1,10) IrT-U191 <br /> a Site Name c Pilon No <br /> ,JOI Vn3 til 1 i r •t fir, J ;;11t T1s 1 t r r+ f�i i ry <br /> b Physical Address d Mailing Address <br /> L Iun, �I-- <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 /> tib <br /> f J Pfl- Slrj- s Iii <br /> Noma at Aemnrized Agent Sipnaeae Remo Date <br /> Section IV ASBESTOS (Generatorwmp.l.ea f Ioperator canpill. <br /> a Operator's Name b Operator's Phone No <br /> c Operator's Address <br /> d Special Handling Instructions and additional information <br /> OPERATORS CERTIFICATION 1 hereby declare that the contents of this consignment are fully 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 ac fling 10 applicable International and government regulations <br /> e Operator's Name&Title <br /> Pnrwrype Operatw a S.p wit, Dale <br /> f Name and Address <br /> of Responsible Agency <br /> g 7 Friable ❑ Non Inable ❑ Both %Enable %nonfriable <br /> Operator refers to Ina company which awns leases operates controls or supervises the facility,being demolished or renovated or the demolition or renovation Operation or both <br /> R ONLY THROUGH RFI,UARCO CONTRACT TRANSPORTER RETAIN ® 26p 72pB 597 <br />