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•HAZARL.,IUS SPECIAL WASTE &�BESTOS MANIFEST <br /> If waste es asbestos waste Completb Sxbongl II Ill and Iv No. 907614 0 7 6 4 4 <br /> It waste 1s NQJ asbestos waste compiete only Sections l 11 and]it ��I J 1 Y] i <br /> n t GENERATOR {Generator completes au of Se0[lan t! <br /> I rotor Name \,+,tt >f, tri b Generating Location <br /> 1_�JJJL llltt l,jir fit <br /> Address '_` -; + "' r d Address <br /> T - 'n <br /> a Phone No T t i --17111 t Phone No <br /> t owner of the generating facility differs from the generator provide <br /> 3 Owners Name I "m' h Owners Phone No TYPE <br /> BF]WASTE CODE Containers OM METAL DRUM <br /> DP PLASTIC DRUM <br /> B BAG <br /> i Description of Waste 1 t r' ti,i'l k Quantltv Unit No TYPE BA 6 MIL PLASTIC BAG <br /> or <br /> T TRUCK WRAP <br /> O -OTHER <br /> GENERATOR S CERTIFICATION I hereby ceroty 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 properly described classified and packaged artd 1s in proper condition for transportation according 10 P POUNDS <br /> applicable regulations AND It the waste is a treatment residue of a previously restricted hazardous waste subject to the Land Disposal Y YARDS <br /> Restrictions I certify and warrant Mg <br /> at the waste has been treated 1n accordance with the requirements of 40 CFR Pan 268 and ie no longer a M' CUBIC METERS <br /> hazardous waste as defined by 40 CFR Part 261 +1 ,f, r r rl1 kc'S t ;1, k 1 1 1 1, I f c Y' CUBIC YARDS <br /> _ O OTHER <br /> Generator Authorized Agent Name Sigpature 1 F _ �r Shipment Date <br /> Section H TRANSPORTER Generator complete a-d Tran�nsp0rte ii O1ftp1eettee� <br /> TRANSPORTER] TRANSPORTER]] <br /> [}11.1 tl,l � rbi 1 ,III_ [I <br /> a Name h Name <br /> r <br /> it i+1 _r <br /> b Address 1 Address <br /> t <br /> r\ Al <br /> c OrlvetNewAiii itle �� f 1 DriverNamelTitle <br /> -�t PRINTT/PE PRINTT/PE ! <br /> d Phone No a Truck No � k Phone No I Truck No <br /> f Icle License NodState ) - { f- �' .-w m Vehicle License No/State <br /> owledgement of Receipt of Materials Acknowledgement of Receipt of Materials <br /> .s u `. Cr <br /> g � -,,- �•-r� � n <br /> OMer a, Nie \ Sa1 eM Da[e Driver sibriatum <br /> Sh,merit Dare <br /> Section III DESTINATION {Generator completes a-d,destination site completed 8-1) <br /> bra I ru„Still <br /> a Site Name c Phone No <br /> b Physical Address d Mailing Address <br /> ft 'bet 1, _ r1�' { 1\rltrr4l , ti�i <br /> a 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 /> Named Aulh0012ed Agent signature RKapt{late <br /> Section 1V ASBESTOS (Generator mmPiete a-d t It•Operator completes 9) <br /> a Operators Name b Operators Phone No <br /> c operators Address <br /> d Special Handling Instruchons and additional Information <br /> OPERATORS CERTIFICATION I hereby declare trial ore contents of this consignment are tufty and accurately deschhed above by proper shipping name and are classified <br /> packed marked and labeled and are In ail respells In proper condition for transport by highway according to applicable international and government regu�l-atiiornns-�--�-�� <br /> s Operators Name&Title <br /> Pnnt/Type Operator s signature Date <br /> I Name and Address <br /> of Responsible Agency <br /> g ❑ Friable ❑ Non friable ❑ Both o friable °o nonfriable <br /> Operator refers to the company which owns leases operates controls or Supervises the facility being demolished or renovated or the demDIM011 or renovation operation or both <br /> OER ONLY THROUGH BPI 1 UARCO CONTRACT .r ® zoo noe sr9s <br /> TFiAIVSPORTE�i RE AIN <br />