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n wdsle�o n,✓eerw whale waste <br /> complete <br /> ie pleteonl ti s 1 i v No. �J U I`f 111 <br /> If waste as�Z asbestos waste complete Only Sections 1 ll and I11 <br /> section I GENERATOR (Generator completes all of Section t) <br /> Generator Name ] 11 ��t fi ort,,n' b Generating Location r - <br /> Address p15Pll_I l,�1 �r _ LL lits f _ <br /> ' i t ' d Address - ," t i a l 1 ti i l 1 <br /> ticr., t+„ T '-_5 - ,S to it <br /> No 1 u- 7 v Z i Phone No <br /> I owner of the generating facility differs from the generator provide <br /> I Owner's Name F tiult Lualp jjju l 4 h Owner's Phone No 11r1f <br /> TYPE <br /> BFI WASTE CODE [ Containers OM METAL DRUM <br /> DP PLASTIC DRUM <br /> B BAG <br /> Description of Waste it t It Ouanh / ua No TYPE BA 6 MIL PLASTIC BAG <br /> or WRAP <br /> T TRUCK <br /> O OTHER <br /> GENERATOR S CERTIFICATION I hereby certify that the above named matenal is not a hazardous waste as defined by 40 CFR Part 261 or UNITS <br /> any applicable state law has been properly descnbed classified and packaged and is in proper condition for transponallOn according to P POUNDS <br /> appiicable regulations AND it the waste is a treatment residue of a previously restricted hazardous waste subject to the Land Disposal Y YARDS <br /> ResmcuorLs t certify and warrant that the waste has been treated,n accordance vnth the retfuilements of 40 GFR Part 268 and is no longer a M' CUBIC METERS <br /> hazardous waste as defined by 40 CFR Part 261 t i• [ M f I„ t Y' CUBIC YARDS <br /> J <br /> 1 J O OTHERr- <br /> Generator Authorized Agent N e `�gnatura _ L "4/t / L Shipmenl Date <br /> Section II TRANSPORTER (Generator complate a-d Ira="itcorn,tet;�r-n <br /> TRANSPORTER[ TRANSPORTER11 <br /> Dill ltd Tr .,, k#rr_ In <br /> f Name h Name <br /> 7 Address I Address <br /> Driver NameTitle .r `�r'r j Driver Name/Title <br /> PRINTlTYPE PRINTlrYPE <br /> I Phone No a Truck NO y9�/ k Phone No I Truck No <br /> Vehicle License NodState S,�j�T^��' !ir s -' 7:. Z m Vehicle License No/State <br /> Acknowledgement of Receipt of Matenals Acknowledgement of Receipt of Materials <br /> 1 r� / n <br /> Omar S Sh, aril Date DnwX Signature Sh, e t Dara <br /> DESTINATION iGonersW eorhplataa a-d destination aite completes s-f) <br /> dfl -t i, Litt Landfill -JUt II--1)IL L <br /> a I Name c Phone No <br /> 14 ,' t 't, - -(o Ru itl L I, s Nil u <br /> 1 Physical Address tl Mailing Address <br /> Lixc,lluott J I`7-10) <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 /> Niinie of Authonzed <br /> Agent S"tuie Receipt Date <br /> Section IV ASBESTOS (Generstdr complete as t g Operator completes a) <br /> a Operators Name b Operator's Phone No <br /> Operators Address <br /> I Special Handling Instructions and additional Information <br /> OPERATOR'S CERTIRCATION ;hereby declare that the contents of Sus consignment are fully and accurately descnbed above by proper shipping name and are classified <br /> Decked marked and labeled and are in all respects in proper condition for transport by highway according to applicable,ntematlonal and government regulations <br /> a Operators Name&Title I T-77 <br /> PnnvType Operamrs Signature Date <br /> Name and Address <br /> of Responsible Agency <br /> 3 ❑ Fnable ❑ Non triable ❑ Both %inable %nonfnahle <br /> Otlerator refers to the company which owns leases operates controls or suparvrsm the facility being demolmhad o renovated or the demotidon or renovation operation or both <br /> REORDER ONLY THROUGH BFI/UARCO CONTRACT TRANSPORTER RETAIN © 2so z2oe ssa <br />