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N®N-HAZAR&rUS SPECIAL WASTE &�.JBESTOS MANIFEST <br /> + If waste Is asbestos waste complete Sections 1 It [if and IV <br /> No. 907943 <br /> It waste Is t=asbestos waste complete only Sections f It and ID <br /> G"EiRATOR {aensraeor eomd.oee etl at SriCtbn A <br /> EL Generator Name -t_ ,.n m,,4f, ' b Generating Location <br /> + <br /> C Address F'tltlr7 � i ri +`t S x F a d Address <br /> linrlST.lh TN 7- <br /> e Phone Not^i �'+t ---,; _ t Phone No <br /> It owner of the generating facility differs from the generator provide <br /> g Owners Name Frkr,n r,-R�an� i h Owner's Phone No <br /> LYP_E <br /> i BFI WASTE CODEt 1 - Containers OM METAL DRUM <br /> DP PLASTIC DRUM <br /> 13 BAG <br /> J Description of Waste lin,, 11—.,r I k Quanti Until No TYPE BA 6 MIL PLASTIC BAG <br /> m m T TRUCK <br /> O OTHER or <br /> WRAP <br /> GENERATOR'S CERTIFICATION I hereby candy trot the above named rnatens]is not a hazardous waste as defined by 40 CFR Part 261 or UNIn <br /> any applicable state law has been property dsscnbed classified and packaged and is in proper condition for transportation according to P POUNDS <br /> applicable regulations,AND if the waste Is a treatment reaidw of a previously restricted hazardous waste subject to the Land Disposal Y YARDS <br /> Restriction I certify and warrent that the waste has been treated in aocomarice with the requirements of 40 CFR Part 266 and Is no Longer a M' CUBIC METERS <br /> hazardous waste as datkred by 40 CFR Part 261Y' CUBIC YARDS <br /> tt t ,t i t(TuCty( Ipt 'r .s O OTHER <br /> H A�4 0"5& <br /> AUUtonzed Agent Nang signature Shipment Date <br /> - TRA SPORTER f3arwra oFrw to aid' Tre p~fq —n' ire-yx-« <br /> — _ TRANSPORTER] TRANSPORTERII <br /> a Name 91 t 1 it d T i i, 4 Iii h Name <br /> 5 <br /> I) Address I Address <br /> r- <br /> c Driver NametTtle fn _ �__._ i Driver NamwTdle <br /> r PRINTfrYPE PRINTRYPE <br /> rte No ] J t 1 r a Truck No <_y k Phone No I Truck No <br /> cie License No/State 5,r `. m Vehicle License NoJState <br /> Acknowledgement of Receipt of Materials Acknowledgement of Receipt of Materials <br /> g U tI z n <br /> S=DrN.r luta cit Date oiwer Signature Shipment Dam <br /> III DEST]NATION (Genwator comptetm a-d desnna&m sire c=wetw ad) <br /> a Site Name n` ' t I i„I t "t I c Phone No <br /> b Physical Address !l t71 " t E i l I L d Marling Address ' <br /> I <br /> e Discrepancy Indication Space <br /> I hereby codify that the above named matenal has been accepted and to the best of my knowledge the foregoing is true and accurate <br /> ,r L , <br /> f war at Aueionmil Agent! S gnaftva Reeapt Dam <br /> Section IV ASBESTOS {Generator comprere a-d f a opens or cpnpletss a.} <br /> a. Operators Name b Operators Phone No <br /> c. Operators'Address <br /> d Special Handling Instructions and additional information <br /> OPERATOR'S CERTIFICATION I hereby declare that the contents of this consignment are fully and accurately descnbed 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 /> e Operators'Name&Title II ! f__L <br /> Pm,yrypa Operatort,Signature Date <br /> f Name and Address <br /> of Responsible Agency <br /> g ❑ Friable ❑ Non friable ❑ Both 4'a friable %nonfnable <br /> Ismtor refers to the company which owns leases operates controls or supervises the facility being demokshad or renovated or the demolition or renovation operation or oath <br /> REORDER ONLY THROUGH 8FI!UARCO CONTRACT TRANSPORTER RETAIN 9 —7213135r93 <br />