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W.HAZARD�,tr.US SPECIAL WASTE & i-SOESTOS MANIFEST <br /> If waste Is asbestos waste complete Sections I It [[i and IV <br /> 907961��a <br /> if waate is NOT asbestos waste complete only Sections I It and€it J J <br /> t ectian F -•t GENERATOR (Generator completes allot Section tI <br /> a. Generator Name t cyan 'ansa( b Generating Location <br /> 2k<�4ti1 t�{;ysr <br /> c Address tl Address <br /> Hrllt r 11 T� ^�•__ i <br /> I•1 <br /> a Phone No I'13 1 "51,-"""' f Phone No <br /> If owner of the generating facility differs from the generator provide <br /> g Owner's Name E¢'-rt hh h Owner's Phone No <br /> i BF1 WASTE CODE m Containers DM METAL DRUM <br /> DP PLASTIC DRUM <br /> I Description of Waste °"i1 u ' t I B BAG <br /> k Ouantt units No TYPE BA 6 MIL PLASTIC BAG <br /> m m or WRAP <br /> D 0T TRUCK <br /> O OTHER I <br /> GENERATOR S CERTtFiCATION I hereby comfy that the above named material is not a hazardous waste as dehned by 40 CFR Pan 261 or UNITS <br /> any applicaNe State law has been property described ciassrTied and packaged and is in proper condition for transportation according to P POUNDS <br /> applicable regulation AND If the waefe Is a treatment residue of it previously restricted hazardous waste subject to the Land Disposal Y YARDS <br /> Restnctrens I certify and warrant that the waste has been treated in accordance with the requirements of 40 CFR Pa*t88 and is no longer a M' CUBIC METERS <br /> hazardous waste as defined by 40 CFR Part 281 C 1 r t I t 1 S Ye CUBIC YARDS <br /> �i}e-Y\ i ! O OTHER <br /> Generator Authorized Agent Name Signature / J 17 y� Shipment Date <br /> Secttonit TRANSPORTER (Generation cOmpletea-dr Trar:porte,11t nt <br /> TRANSPORTER] TRANSPORTERII <br /> I <br /> !Jj I 'ii Ti tir k I at. I <br /> a Name h Name <br /> b Address I Address <br /> i)tt r 1 r <br /> ver Narrlan!"itle / i I Driver Namw7itle <br /> 1 . T'i'M. ✓r,/PAi&rr5WE PRINT/TYPE <br /> hone No a Truck No _ t kPhone No I Truck No <br /> r7� lam, <br /> f Vehicie License NGJStater c m Vehicle License NoJState <br /> AcknowledgementofRe et of Matenals� Acknowledgement of Receipt of Matertals <br /> g l /f'/ r ^ n <br /> bAver N'` Sh mens Oale s 11 brlver 5 ttua Shi ern bete <br /> Section Ea DESTINATION {Generator opmptetes a d desdnatwn sora cwmytaoes a t f <br /> a Site Name c Phone No <br /> IU01 Not t Ir 4r1�'r n nn• k nt! v irt- t f <br /> b Physics!Address d Marling Address <br /> f I. Imot <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 /> 0- it <br /> r4arne of Aurhpnxed Apsee Signature � ..-err Receipt bels <br /> Suction IV ASBESTOS {Generatorcompistea-d f o Operator•oomptetesal <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 ctasslbed <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 /> a Operator's'Name&Title <br /> PnntrType z Operator s Sgatil re bate <br /> f Name and Address <br /> of Responsible Agency <br /> Friable El Non triable Both °°friable0 %nonlnable <br /> Operator refers to the cpmpany which owns eases operates convois or supervises the facility being demoiished or renovated or the demolition or renovalion operation or both <br /> REORDER ONLY THROUGH gFl!UARCO CONTRACT TRANSPORTER RETAIN ® 260 7206 5193 <br />