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i NON-HAZARD,,US SPECIAL WASTE & .-SBESTOS MANIFEST <br /> if waste is asbestos waste complete Sections 1 11 lit and Iv w 1 O. 907953 J O 7 9 J <br /> .3 C O <br /> If waste is UQJ asbestos waste complete only Sections l 11 and III 'Y J <br /> W n I GENERATOR (awwratorcompietesaeotsectrnv+r) <br /> Generator Name s' " b Generating Location <br /> Address - d Address <br /> Phone No +I l = f Phone No <br /> owner of the generating facility dialers Irom the generator provide <br /> Owner's Name "`" h Owner s Phone No <br /> TYPE <br /> BFI WASTE CODE Containers DM METAL DRUM <br /> DP PLASTIC DRUM <br /> B BAG <br /> Description of Waste " t ' k Quantity Units No TYPE BA 6 MIL PLASTIC BAG <br /> or WRAP <br /> rE i T TRUCK <br /> J O OTHER <br /> GENERATOR S CERTIFICATION I hereby Co rtity that the above named material is not a hazardous waste as defined try 40 CFR Pan 261 or UNITS <br /> any applicable state raw has been properly described classified and packaged and is in proper condition for transportation accorduig to P POUNDS <br /> sppbeabre 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 comfy and warrant that the waste has been treated in accordance with the requirements of 40 CFR Part 268 and is no longer a M' CUBIC METERS <br /> hazardous waste as defined by 40 CFR Part 261 j1 ' I i .r+ + ! I Y' CUBIC YARDS <br /> 1 1,11 ! l I' y q o OTHER <br /> Generator Authorized Agent Name Signature f S } I Shipment Date <br /> Section II TRANSPORTER Gewwwator cbitrplele a-d <br /> TRANSPORTER I TRANSPORTER H <br /> Lt1} 7i pl itr <br /> i Name In Name <br /> r Address i Address <br /> @ti it <br /> Driver NamarTttle 'e r ! Driver NamaMtle <br /> I"t 1_t f PRiNTiTYPE PRINTITYPE <br /> io No a Truck No r� rte k Phone No I Truck No <br /> Vehicle License Na.IStateS}'-"C-/77 ,f k.1_ _ :7'r7_.._ m Vehicle License No/Slate <br /> Acknowledgement of Receipt of Materials Acknowledgement of Receipt of Materials <br /> 3 n <br /> O we Stn rrienr Date Driver swiaturri Sh t Dare <br /> Secdon III DESTINATION (Generator completes a-d,eesrination site completes e4) <br /> RFT vtir it 1-1 tin+i 1 ' t , -,10 :7 rl <br /> a Site Name c Phone No <br /> b Physical Address d Mailing Address <br /> e Discrepancy Indication Space <br /> f hereby certify that the above named material has been accepted and to the best of my knowledge the foregoing is true and accurate, <br /> Name of Aumonzed Agent sqp ujro Reow Date <br /> Section IV ASBESTOS (Generator complete"f 8 Operator'complates e.k <br /> a Operator's Name b Operator's Phone No <br /> c Operators Address <br /> d Special Handling Instructions and additional information <br /> OPERATOR S CERTIMCATION 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 regulations <br /> a Operator's Name&riitte IIIII II <br /> Pmtrrypo Operator s S.9-tum Dare <br /> I Name and Address <br /> of Responsible Agency <br /> g ❑ Fnable ❑ Non triable ❑ Both °6 friable %nonfnable <br /> leator refers to the company which owns (eases operates controls or supervises the facility being demolished or renovated or the demolition or renovation operation or both <br /> REORDER ONLY THROUGH BPI/UARCO CONTRACT TRANSPORTER RETAIN ® isa7¢d6 Brea <br />