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N-HAZARb.-JUS SPECIAL WASTE & ASBESTOS MANIFE5T <br /> If waste Is asbestos waste complete Sections l Il 111 and tV No 9 0 7 Q S(19 <br /> It waste Is&Q,asbestos waste complete only Sections 1 11 and s11 <br /> ection I GENERATOR (Generator completes all of seoebn q - <br /> I <br /> tit, ',Zih�ltt k b Generating Location <br /> r Name ,Ir t51 rt 1 u tin i 1r <br /> �{ '_11 Rsfl ��+�+� ,ti+Ct (411 rt rl <br /> Address d Address <br /> 1�4iIbL iii �� 77$��-.Sn <br /> Phone No f IS, 1 Phone No <br /> owner of the generating facility differs from the generator provide , <br /> Owner's Name EX h Owner's Phone No <br /> TYPE <br /> Containers DM METAL DRUM <br /> BFI WASTE CODE OP PLASTIC DRUM <br /> B BAG <br /> �+t Hn. a lou moi,i i k Quante Una No TYPE BA 6 MIL PLASTIC BAC <br /> Description of Waste or WRAP <br /> tta U T T TRUCK O OTHER <br /> UNITS <br /> GENERATOR$CERTIFICATION I hereby tartly(hal the above named material to not a m proper r eco stdi as condition ij,transportation ned by 40 RPart accordin 1 to P POUNDS <br /> any applicable state law has been property described classified and Packaged anof <br /> d Is+n <br /> 9 <br /> applicable regulation ANO II the waste is a treatment residue of a previously restricted hazardous waste subled to the Land Olspasai Y YARDS <br /> CUBIC MET <br /> Restrictions I tardy and warrant that the waste has been treated in accordance with the requlrerrients or a0 CFR Pan 286 and I9 no longer a M' CUBIC YARDSS <br /> hazard"waste as defined by 40 CFR Pan 261 �11 ,11t IeUklt't V1 F""' <br /> O OTHER <br /> If <br /> , Shipment Date <br /> Generator Auttwnzed Agent N. a Signelure+ <br /> r <br /> Trangpdrtar 1 complete eq <br /> Section II NSPORTER Generator complete e d T iter tE tom h.t <br /> TRANSPORTER! TRANSPORTERII <br /> 01sIat,1 lt,itrii+. lit. In Name <br /> a Name <br /> 21}° I Address <br /> b Address <br /> Bron Cr, `)CI <br /> c Driver Name/ritle , - - I Driver Namerrfife pRINTmPE <br /> I ; Vh I-F aril PRIWr YPE i Truck No <br /> d Phone No <br /> e Truck No k Phone No <br /> f Vehicle License NoJState m Vehicle license NOJState <br /> owiedgement of Re elQt o Materials Acknowledgement of Receipt of Materials <br /> / <br /> g s i Date <br /> Omar s lure s l t oath gmer si 118tiere <br /> Section III DESTINATION (Generator 15101 <br /> &d,dea6natlon site comperes e t] <br /> I52JI lt"-JiJt <br /> BFT Vctary Rd Lattdf I i I c Phone No <br /> a Site Name }pJ' Rr+,1+1 <br /> 4001 but ttl RoaLi d Mading Address <br /> b Physical Address <br /> e Discrepancy Indication Space <br /> cepted�to the best of my knowledge the foregoing is true and accurate <br /> I hereby comfy that the above named material has been ac <br /> a az-r 3tJUx 2002 W <br /> r PD= <br /> f Nsignature PAC.0 Onto <br /> ae+.d wiinrrz.d AW" <br /> Section IV - ASBESTOS (generator ooriwlow ad.f g Operator ebrrtpletss e) <br /> a Operators Name b Operator's'Phone No <br /> c Operators'Address <br /> d Special Handling Instructions and additional information <br /> OAERATOR S CERTIFICATION f hereby declare that the co Items of this consignment ars fully and accurately described above by Proper shipping Hama and are classified <br /> packed marked and Labeled and are In ail respects in proper condition for transport by highway according to applicable international and government regulations <br /> e Operators Name&Title operawrs sq-W. °819 <br /> PnnVType <br /> I Name and Address <br /> of Responsible Agency <br /> g ❑ Friable ❑ Nan finable ❑ Bath <br /> i friable %rionfrlable <br /> Operator relers to the company which owns leases operates controls or Supervises the laeirty being demol'Shed Or renovated or the demolition Or enovahon operation or both <br /> ® 260 7209 5193 <br /> �RDtRONLY THROUGH RFI ILARGO CONTRACT TRANSPORTER RETAIN <br />