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S SPECIAL WASTE & --.5BEST0S MANIFEST <br /> AR0.r <br /> If waste Is asbestos waste complete Sections t Il lit and tV No. 9 071 9 51 <br /> If waste is U=asbestos waste complete only Sections l r'1 and 111 <br /> • GENERATOR (Generator completes allot section r) <br /> Generator Name �' �' b Generating Location <br /> Address c t�j l r,�)t 'r n, d Address <br /> H,ntl.ttet, T <br /> Phone No i i f Phone No <br /> owner of the generating facility differs from the generator provide <br /> Owner's Name h Owner's Phone N0 <br /> TYPE <br /> ETAL DRUM <br /> BFI WASTE CODE I Containers DP PLASTIC DRUM <br /> B BAG <br /> Description of Waste h i) t r'! i k Quant1tv uNts No TYPE M BA 6 MIL PLASTIC BAG <br /> or WRAP <br /> T TRUCK[i] <br /> O OTHER <br /> GENERATOR S CERTIFICATION I hereby Comfy that the above named material Is not a hazardous waste as defined by 40 CFR Pad 261 or UNITS <br /> any applicable state law has been property descnbed classified and packaged and is in proper condition for transportation according to P POUNDS <br /> appscabfe regulations AND It the waste is a treatment residue of a previously restricted 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 GFR Pan 268 and is no longer a YM', ClUJBIC METERS <br /> YARDS <br /> hazardous waste as defined by 40 CFR Pan 261 O OTHER <br /> Generator Authorized Agent Name Ssgnatum Shipment Date <br /> Transporter t complete e-g <br /> Section II TRANSPORTER Generator compute ea Traria ern ten n <br /> TRANSPORTERI TRANSPORTER11 <br />! Name it , K _ t, h Name <br />� Address Address <br /> c Driver Name/Title , 4 I Driver Name/Title <br /> PRINTfTYPE <br /> a ' I PRI PE -�� k Phone No I Truck No <br /> d e No a Truck No <br /> v <br /> F le License NoJState _r r m Vehicle License NoJState <br /> Acknowjpdg�ment 9r' etpt of Materials <br /> g Acknowledgement of Receipt of Materials <br /> n <br /> Drn f tum � Sn enata Dr„rar tura 5 1 Data <br /> Seci6ory III DESTINATION (Generator oomptates a-d desanation oma cprrlpltnes e-f) <br /> r'5 , i I t ilr <br /> a Site Name c Phone No <br /> i ` t <br /> b Physical Address d Mailing Address -- <br /> s <br /> 11 I laui, f-- <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 Norris of Auewnzed Agent Signaeua ROOw Owls � <br /> Section TV ASBESTOS fGonerstdr complete ad 1 g OPOramr umplefea e) <br /> a Operator's Name b Operators Phone No <br /> c Operator's Address <br /> d Special Handling Instructions and additional sntormation <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 labeled and are in all respects in proper condition for transport by highway according to applicable international and government reguiabons <br /> a Operator's Name&Title Operawra signature Dais <br /> Print/Type <br /> I Name and Address <br /> of Responsible Agency <br /> g ❑ Fnable ❑ Non friable ❑ Both %friable %nonfnable <br /> orator refers to the company which owns leases operates comrais or supervises the facility being demolished or renovated or the demolition or renovation operation or both <br /> 0 <br /> ® Z---.. <br /> REORDER ONLY THROUGH OR!UARCO CONTRACT TRANSPORTER RETAIN <br />