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t <br /> .JN-HAZARCN . US SPECIAL WASTE & i-�BESTOS MANIFEST <br /> If waste is asbestos waste complete Sections I [[ [[I and[v No. 907944 <br /> IF waste is tM asbestos waste complete only Sections[ II and t11 <br /> GENERATOR (Gerieratormrrtpf�6aasJlafSecilort{} <br /> iL Generator Name a ' b Generating Location <br /> a Address t d Address " <br /> Ii T - <br /> e Phone Na f Phone No <br /> If owner of the generating facility differs from the generator provide <br /> g Ownees Name h Owner's Phone No <br /> TYPE <br /> i BFI WASTE CODE Containers OM METAL DRUM <br /> OP PLASTIC DRUM <br /> B BAG <br /> Description o1 Wasia I k Quenu Y TYPE BA B MIL PLASTIC BAG <br /> or WRAP <br /> T TRUCK <br /> I O OTHER <br /> GENERATOR 5 CERTIFICATION I hereby certify that the above named matenal Is not a bazar ous waste as defined by 40 CFR Part 261 or UNITS <br /> any applicable state law has been property"scribed classified and packaged and is In proper condition for tranaportab*n according to P POUNDS <br /> applicable regulations AND If the waste is a treatment residue of a previously msfrtcted hetardome waste subject to the Land Disposal Y YARDS <br /> L Restrictions I cerbfy and warrant that the waste has been treated in accordance with the requirements or 40 CFR Part 268 and is no longer a M' CUBIC METERS <br /> hazardous westgg as defined by 40 CFR Part 261 n Y' CUBIC YARDS <br /> 11,r +�ilTf�—rj ` r ( r / ( O OTHER <br /> A'k i I u,, v� t <br /> Generator Authonzed Agent Nam Signa6irs Shipment Date <br /> 5action II TRANSPORTERGeneratwrAmpiota ae- 7,`a"ansp'=n c�"'potr,I t°�,,t <br /> TRANSPORTERI TRANSPORTERII <br /> t'itlfv i T „ l <br /> a. Name h Name <br /> b Address i Address <br /> c Driver NamalTitle I Dover Name/Titlo <br /> l r r i lr,r PRINT/rVPF ' PRIMRYPE <br /> dNo a Truck No _-,ql ?.l k Phone No I Truck No <br /> J# <br /> e Lacense NoJState SPS Ssl Y / I /Ii ,,n �_ i m Vehicle License No/Slate <br /> nowledgement of Receipt of Matenafs Acknowledgement of Receipt of Materials <br /> DrIvALOgnsivre ShWneM Date I Driver wre Shtornent Date <br /> Section FII DESTINATION (Ganeratorcompleteaa-d destinattat arta completes e-t) <br /> a Site Name c Phone No <br /> b Physical Address 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 /> f <br /> Name of Auewnzep►sen signature Recerot caro <br /> Section IV rr ASBESTOS (Gwwatormplem a.a.f.g ow for mmpkfte e.) <br /> r <br /> a Operator's-Name b Operator's'Phone No <br /> , <br /> c Operator's Address <br /> d Special Handling Instructions and additional Information <br /> OPERATORS CERTIFICATION I hereby declare that the contents of this consignment are fully and accurately described above by proper snipping name and are classified <br /> packed marked and labeled and are in all respects In proper condition for transport by highway according to applicable miamational and government ragulalidnS , <br /> a Operator's Name&Title l <br /> PnnVrype Operaiara S,gnmuis Dare <br /> f Name and Address <br /> of Responsible Agency <br /> g ❑ Friable ❑ Non friable ❑ Both i friable %nonfnable <br /> son refers tb the company wnicn owns leases operates controls or st,pervises the facility being demolished Or renovated or the demoln,on or renovation operation or both <br /> RE R pNLY THROUGH BFI/UARCO CONTRACT TRANSPORTER RETAIN 0 2t30.72ce Sr47 <br />