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eu-s-s---P-IECIAL WASTE f& , ,SBESTOS MANIFEST <br /> If waste Is asbestos waste complete Sections f Il 111 and IV ^'0. 007'13 J O 7 O 1 3 <br /> If waste is UQj asbestos waste Complete Only Sections 1 11 and 111 N <br /> I GENERATOR (Generator completes ail of Section 1) <br /> rotor Name ] "' b Generating Location <br /> Address - d Address <br /> Himt l L _ <br /> Phone No "'G 7' i f Phone No <br /> owner of the generating facility differs from the generator provide <br /> Owners Name �' �" ' h Owners Phone No 7 Lli <br /> TYPE <br /> BFI WASTE CODE 71� Containers DM METAL DRUM 1 11 <br /> DP PLASTIC DRUM <br /> B BAG <br /> Description of Waste ' I k Quant, Units No TYPE BA 6 MIL PLASTIC BAG <br /> m J m or WRAP T TRUCK <br /> O OTHER <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 applicable state law has been property described classified and packaged and is In proper condition for transportation according to P POUNDS <br /> applicable regulations AND It the waste is a treatment residue of a previously restricted hazardous waste subject to the Land Dlsposai Y YARDS <br /> Restr,cLons I certify and warrant that the waste has been treated in accordance with the requirements of 40 CFR Pan 266 and s no]ringer a M' CUBIC METERS <br /> hazardous waste as defined by 40 CFR Part 261 1 1 t > t r t YS CUBIC YARDS <br /> O OTHER <br /> 1t�r1i E"F' a ` , ! q -1 _�.-1__ r / <br /> Generator Authon;ed Agent Namei Si rp lature M r ,( Shipment Date <br /> Section II TRANSPORTER Generatorcom mead Transporterlcomplelite te,rg <br /> P Tran iter It h-n <br /> TRANSPORTERI TRANSPORTERII <br /> 1)11 11. T +Il 1 I* _ <br /> I Name _ __ ___ _ h Name <br /> - <br /> L Address I Address <br /> f�r"t+•r7 L L rs- <br /> Driver NamaoTide ham✓ J 1 Dmor Nama(Tiyo.. e- <br /> I..1 ;34 <br /> J4 i ,LI PRINT)TYPEJ PRINTrrYPE <br /> I Phone No a Truck No k Phone No I TruckAo <br /> r <br /> a License No/State '� • f e, r m Vehicle License No/State <br />�wle2�=atenals n Acknowletlgement of Receipt of Materials <br /> � r <br /> Omer Shipman,Dare 0-.5 nature shiprns,,l Date <br /> Section DESTINATION (Generator completes ad destination site wmplelas e4) <br /> E Ltt 1, <br /> t Site Name c Phone No <br /> 4 i <br /> it f li <br /> I Physical Address d Malting Address <br /> Ifor t <br /> t Discrepancy indication Space <br /> I hereby cartify that the above named material has been accepted and to the best of my knowledge the foregoing is true and accurate <br /> Narr o of AuLhwzoo Agenl SgnaNre ✓ Reoetpt Date <br /> Section IV ASB ESTOS ;Generator complets a-d t Ir Operator completes a) <br /> a Operator's Name b Operators Phone No <br /> Operators Address <br /> 1 Special Handling Instructions and additional information <br /> OPERATORS CERTIFICATION I hereby declare that the contents of this consignment are fully and accurately descnbed above by proper shipping name and are dassftied <br /> sacked marked and fabeied and are in all respects in proper condition for transport by highway according to appltcable international and govemmani regulations <br /> 9 Operators Name&Title <br /> Pnrx/Type Operator a Signature Dale <br /> Name and Address <br /> of Respons^Agency <br /> 1 <br /> g GFrage ❑ Non friable ❑ Both °o friable %nonfnable <br /> Operator refers to the Company whish owns leases operates eontrois or supervises the facility being demolished or renovated or the demoiihon or renovation operation or twin <br /> A&ONLY THROUGH BFI I UARCO CONTRACT TRANSPORTER RETAIN 4 1.12.a 5 33 <br />