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,lfaHAZARM.AJS SPECIAL WASTE & ;"'~42BESTOS MANIFEST <br /> Itwaste Is asbestos waste complete Sections 1 11 lit and IV No• 907957 <br /> It waste is_%n asbestos waste complete only Sections 1 11 and lit <br /> y GENERATOR. (Generator ramoletas all Of Se xi n A <br /> t rs ar • b Generating Location <br /> Generator Name <br /> `ICi ir�f` t'��• tr1,..;.t+rrt t ' ' d Address <br /> Address <br /> iter, tit:Ertr 1 -' r t +, r ' tr 1 <br /> Phone No i_! I ` I Phone No <br /> owner of the generating facility differs from the generator provide <br /> Owners Name~ <br /> K , r, t 3 Owner's Phone No <br /> TYPE <br /> • [E = Containers DM-METAL DRUM <br /> BFI WASTE CODE DP PLASTIC DRUM <br /> S BAG <br /> N,,�, FE. t U cr 4 Qua nti tints No TYPE SA 6 MIL PLASTIC BAG <br /> Description of Waste ❑ m T TRUCK or WRAP <br /> O OTHER <br /> UNIT <br /> GENERATOR$CERTIFICATION l hereby tinily that the above named material is <br /> at is hate aqe s�n,lition aeh�bry 40 pportationRaccordiPart ng too LYY�A <br /> NDS <br /> any applicable state taw has Leen property described classified and pacxa9 r <br /> applicable regulations AND d the waste is a treatment residue of a previously restricted hazardous waste sublect to the Lantl Disposal IRealActronS f caN1y and warrant that ilia waste has been trea[etl m accordance with She raqurrements of 40 CFR Pan 268 and is ria longer aIC fYARDSshazardouswasteasdefinedby46CFRPan261 t z ' r ER <br /> Shipment Date <br /> Generator Authored!}gent Name Signature <br /> Trariaporter F + <br />$ 1 .TRANSPORTER Ge mtarmpfete <br /> eaa-d' T II m <br /> TRANSPORTER1 N <br /> TRANSPORTER II <br /> b►I tat„ u <br /> Tr , kt_fnit, h Name <br /> a Name <br /> P P„ _t' 'I Address <br /> b Address <br /> I%i ,t- <br /> c Driver NamiaMtfe • y - I Dnver Name/Title PRINTI YPE <br /> �PR'Nrrtv �/� I Truck No <br /> �,+ t e Truck No �_ k Phone No <br /> ne No _ �� <br /> frt Vehlcie License NolState <br /> cfe tscense NoJState C J � <br /> Acknowledgement of Recelpt of tenals Acknowledgement of Receipt of Materials <br /> C 2 t <br /> i n g i Date <br /> 9 sr t oat o tva s nue <br /> br rer§22 Lij <br /> SaLt ign'M DESTINATION {Generator compistm a-d,destelatton alta completes e-f I <br /> c Phone No <br /> a Site Name 1 <br /> d Mailing Address <br /> b Physical Address ; t <br /> e Discrepancy Indication Space <br /> opted and to the best of my knowledge the foregoing is true and accurate <br /> I hereby certify that the above named matenal has been acc <br /> t reiix 0 e <br /> Nor"ol Auewnxao ovenl SlpnaW n <br /> Section N ASBESTOS iGenerator complete a� t g Operator oxrtpletes a) <br /> r b Operators Phone No <br /> a Operators IJame <br /> e Operators Address <br /> d Special Handling Instructions and additional information <br /> bed above tty proper <br /> OPERATOR'S <br /> Iced Tmarked erttllabe ad Oand green all respectsre inimpropet the r condlbdnntents tforthis <br /> transportconsignment <br /> by ghway acco ding to applicab enntema onal and government regulations are classified <br /> Owe <br /> e Operators Name&Mile oparalors5gnaw,s <br /> PnnYTyPa <br /> t Name and Address <br /> of Responsible Agency <br /> g ❑ Friable ❑ Non Inable ❑ Both %friable %nonfnable <br /> peralor Warr to the company which owns leases operates Controls or supervises the fatuity oemg demolished or renovated of me demolition or renovation operation of both <br /> © 26ID-120B 5.'93 <br /> REORDER ONLY THROUGH aft)UARCO CONTRACT TRANSPORTER RETAIN __ _ <br />