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QN-HAZARL,.,US SPECIAL WASTE &'—.3BESTOS MANIFEST <br /> I1 waste is asbestos waste complete Sections l it 111 and IV No. �]f1-7 Q d i <br /> it waste is UI asbestos waste complete only Sections 111 and ft[ 1`s 9 U / J 4 1 <br /> I GENERATOR (Generator cornpletea an of Section o <br /> t Generator Name _ b Generating Location <br /> Address -'' d Address <br /> l Phone No - I Phone No <br /> f owner of the generating facility differs from the generator provide <br /> 3 Owner's Name h Owners Phone No <br /> TYPE <br /> BFI:WASTE CODE m Containers DM METAL DRUM <br /> DP PLASTIC DRUM <br /> B BAG <br /> Description of Waste k uantiUnom No TYPE BA 6 MIL PLASTIC BAG <br /> or <br /> m m O OTHE WRAP <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 properly described classified and packaged and is in proper condition for transportation acoording to P POUNDS <br /> applicable regulation$ AND if the waste is a treatment residue of a previously resMeted hazardous waste subject to the Land Disposal Y YARDS <br /> Restrictions I certify and warrant that the waste has been treated in accordance with the requirements Of 40 CFR Part 268 and Is no longer a M' CUBIC METERS <br /> haza75 wartqd�finedby4ocmpal,1261 Y" CUBIC YARDS <br /> }{ �tn Y�It rYrr � /Ji ,�� � F r O OTHER <br /> Generator Authonzad Agent NTO Signa re / Shipment Date <br /> Trrutsporter 1 CorrtPtete a-g <br /> Section H TRA PO RTER Generator complots a� Transportern tom re h r1 <br /> TRANSPORTERI TRANSPORTER II <br /> a Name I1t] it T, lir _ h Name <br /> b Address i s t Address <br /> c Onver Namemtle i Driver NamaMtle <br /> _ PRINTI Y13E PRINTrrYPE <br /> e No l a Truck No / Q k Phone No I Truck No <br /> I <br /> e License NoJState a k l�.r 1 _.,c r}I. _ m Vehicle License NoJState <br /> Acknowledgement of Receipt of Materials Acknowledgement of Receipt of Materials <br /> 4 J v n <br /> Dinar 91tinitture ShEmm Date I P+hwar s4riiitiwS Sni t Data <br /> Section III DESTINATION (Generator compietes a-d deannatfon site mmpietaa e f) <br /> a. Site Name I t I �' I ` ; c Phone No I i <br /> b Physical Address I ' i I d Mailing Address <br /> e 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 /> Name at Authorized Agent Sgnatwe Recnot Qara I ' <br /> Seaton Iy ASBESTOS (Generator complete as f g operator cipwietas a) <br /> a Operator's Name? + b Operator's Phone No <br /> c Operator's 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 described above by proper shipping name and are classified <br /> packed marked and fabefed and are in all respects in proper condition for transport by highway according to applicable international and government regulations I <br /> e Operator's Name&Title <br /> Prmrrtypo Operators Sgnawre .lam <br /> f Name and Address <br /> of Responsible Agency <br /> g ❑ Friable ❑ Non triable ❑ Both %triable %nontriable <br /> Orator refers to the company which owns leases operates controls or supervises the facility being demolished or renovated or the demolition or renovation operation Or both <br /> REORDER ONLY THROUGH BFI 1 UARCO CONTRACT TRANSPORTER RETAIN ® 28i}720D 5+57 <br />