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I US SPECIAL WASTE &,.23BESTOS MANIFEST <br /> If waste is asbestos waste complete Sections 1 II III and IV No. 907945 <br /> �c 5r_s It waste Is%a asbestos waste complete only Sections I II and III <br /> 4 GENERATOR (Deneratoreempietee alt of Sec4on 1) <br /> GatewwName L Cort -tiWU,,, I b Generating Location I 1 <br />?"Address T�L 11218 4 t m y�rl If. d Address <br /> s-Phone No (711il 650-7-ut I Phone No <br /> f owner of the generating facility differs from the generator provide <br /> Ownefs Name EXXOn COmDdlit r+ In Owners Phone No <br /> __ • TYPE <br /> BFI WASTE CODE % I I l I Contalners OM METAL DRUM <br /> DP PLASTIC DRUM <br /> B BAG <br /> Description of Waste neon H l,"[dou ti, ' k, Quante Umts No TYPE BA 6 MIL PLASTIC BAG <br /> or WRAP <br /> I11 I T TRUCK <br /> O OTHER <br /> GENERATOR'S CERTIFICATION 1 hereby comfy that the above named material Is not a hazardous waste as defined by 40 CFR Part 261 Or UNITS <br /> ally applkable state law has been property described classified and packaged and is m proper condition for transportation according to P POUNDS <br /> apphtable regulations,AND.It the waste Is a treatment residue of a previously restricted haxardous waste subject to the Land Disposal Y YARDS <br /> Restrictions,1 certify and warrant that the waste has been treated In accordance weh the requirements of 40 CFR Part 266 and is no longer a M' CUBIC METERS <br /> lie:ardoirs waste as de�inn��dd blr 40 CFR Part 261 a t t h k i e tlt l ' ] I Yr -CUBIC YARDS <br /> `+ t�9••Y4V,,etoy- <br /> f s O OTHER <br /> O G7 <br /> Generator AuthoitzedAjent Name Sire },,/f1 +6.j Shipment Date <br /> S ' SPORTER c:erleretor'tinpiete a T a71dP0f"r[� sr <br /> TRANSPORTER I TRANSPORTER H <br /> a Name ❑f t lard Trnr 1.'iw t tt, h Name <br /> b 'Address <br /> F I Address <br />✓ i i �,i f <br /> * / 1 Driver Name/title <br /> r Namde PRINTRYPE <br /> , i f ! t PRrNx111'P <br /> 0j .No a Truck No /_ k Phone No I Truck No <br /> f Vehicle License NoJStata G �i m Vehicle License NoJSlate <br /> Acknowle e n Ipt of Matenals Acknowledgement of Receipt of Materials <br /> g r n <br /> Onver sae Sh am Oars orrversi neWre Sh n[Oeie <br /> S n III DESTINATION (Generator completes a-d aesdnation site irnrspletas e f l <br /> a Site Name IS F I ti l „ r d 1 +, 11 c Phone No i <br /> ]a ( r %t I r I, 1 , i <br /> b Physical Address d Mailing Address <br /> 11' LIdVs+ '^ 1 ri <br /> a 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 /> i <br /> Nam ot Aulix=ed Agani S,ipiaaua Receipt Dau <br /> Section IV ASBESTOS (Ganeramr complete a-0,f g Opembr Completes e) <br /> a Operator's'Name b Operator's'Phone No <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 descnt)ed 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&Title1 -1J <br /> PnntiType Operators Signature oater <br /> f Name and Address <br /> of Responsible Agency <br /> 0 Friable ❑ Non enable ❑ Both %friable %nonfrrable <br /> Operator refers to the company which owns leases operates controls or supervises the facihty bung demolished or renovated or the dernowiorl or renovation operation or coin <br /> REORDER ONLY THROUGH BPI I UARCO CONTRACT © 260-72065193 <br /> TRANSPORTER RETAIN _ <br />