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-HAZARD,JJS SPECIAL WASTE & .,,3BESTOS MANIFEST <br /> I!waste Is asbestos waste complete Sections 1 Il 111 and Iv No. (�'7 <br /> It waste Is�7 asbestos waste complete only Sections 1 Il and tit N 0 <br /> 921 <br /> Section I GENERATOR (Generator completes all at Section q <br /> for Name <br /> "I b Generating Location -r <br /> 111 i` t r}1Ntr]Ili°' I SII I I _ <br />+~ ress <br /> of Address <br /> '"11111 r II T` -7-1,2-21, ' I <br /> e Phone No I I I '-' 11 f Phone No <br /> It owner of the generating faculty dsffers from the generator provide <br /> g Owners Name tiDtt t-t4i1'a"' L I h Owner s Phone No a' <br /> TYPE <br /> ALDRUM <br /> BFI WASTE CODE } r1 " Containers DP PLASTIC DRUM <br /> 0 BAG <br /> Description of Waste %,rl fldzat rlJua 1 ,i k Quantity BA 6 MIL PLASTIC BAG <br /> or WRAP <br /> I , T TRUCK <br /> O OTHER <br /> GENERATOR S CERTIFICATION I hereby cenity that ate above named material 1s not a hazardous waste as defined by 40 CFR Part 261 or UN ID <br /> any applicable state law has been prop"described classified and packaged and Is In proper condition tar transportation according to P POUNDS <br /> applicable regulations AND it the waste Is a treatment residue of a prevlously restricted hazardous waste subtect to the Land Disposal Y YARDS <br /> Restrictions l centy and warrant that the waste has been treated to accordance with the requirements of 40 CFR Part 268 and Is no longer a M" CUBIC Y' CUBC YARDS <br /> METERS <br /> hazardous waste as defined by 40 CFR Part 261 tit t tf e t 1 p I t r—' It f 11 I ' O OTHER <br /> jS ! err r?q �-(( irCa_ i f <br /> F <br /> Generator Authorized Agent Name Slg rurE_L r / i. Ship <br /> mem Oats <br /> Section II TRANSPORTER Generator complete a-0& T �Ot1B <br /> g �n o�� ) <br /> TRANSPORTERI TRANSPORTERII <br /> 1'i 11191 It Ti t.t1 } i 1-' It], h Name <br /> a Name <br /> b Address F 30\ _rE I Address <br /> 8vr it 9 1-1 <br /> c Driver Narre�tfe _ I Driver NarnelTitle <br /> 'd' PRINrmPE <br /> d Phone NO I J Iti I )J 1cr;� PAINTT'P e Truck No Sit/ _ k Phone No t TruNo <br /> I Vehicle License No/State '�-6C 7;`VIV, _ _ m Vehicle License NoJState <br /> ,glWnowledgement of Receipt of Materials Acknowledgement of Receipt of Materials <br /> n <br /> b �fc.r Stepmem bale Diner S nature sfi, enr Dale <br /> S DESTINATION {Generator completes a-d deatinagcn sae omnpletes a-f <br /> aSite Name OF 1 \ t rt 11 lZLi Ind c Phone No I 11� 4 1 <br /> , . <br /> 10,11 Nit th l'i ^rr rt S i 1 i <br /> 1 b Physical Address d Mailing Address <br /> a Discrepancy indication Space <br /> I hereby certify that the above named material has been accepted and to the best of my�J7 <br /> knowlele'dge She foregoing Is true and accurate <br /> f r•1r� I I Ir iii <br /> Name of Aualalzap Went signeare Recwµl)eta <br /> Section IV ASBESTOS (Generator dompfete a-d,f g,Operator completes a) <br /> a. Operatoes`Name b Operators Phone No <br /> c Operator's Address <br /> d Specht Handling Instructions and additional Information <br /> OPERATORS CERTIFICATION I hereby declare that the contents of this consignment are lulty 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 /> a Operator's Name&Title operators synature Date <br /> PnnYryOe <br /> I Name and Address <br /> of Responsible Agency <br /> g ❑ Friable ❑ Nan Inable ❑ Both °'a triable %nonlnabie <br /> Operator raters to the company which owns leases operates controis or supervises the facility being demolished or renovatPad or the demolition or renovation operation lir both <br /> GER ONLY THROUGH BFt r UARCC CONTRACT �,r 26o-r2oB sea <br /> TRANSPORTER RETAIN <br />