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9 <br /> r •NON-HAZARDOI! SPECIAL- WASTE & ASBES <br /> ,�, ,.,(S MANIFEST <br /> r <br /> If waste is asbestos waste,compIgXe Sections I,11,In and IV. <br /> If waste is NQj asbestos waste,complete only Sections I,II and ID. No- 29'6502 <br /> . - faht tete , <br /> a. Generator Name: / [It' r b. Generating Location: <br /> c. Address 41W I P d. Address: <br /> e. Phone No.: 2 O ] b o 0 C f. Phone No.: <br /> If owner of the generating facility differs from the generator,provide: <br /> g. Owner's Name: h. Owner's Phone No.: <br /> TYPE <br /> i. BFl WASTE CODE A] 9 ` Containers DM-METAL DRUM <br /> DP -PLASTIC DRUM <br /> B -BAG <br /> j. Description of f waste:—�Ct1 4 J{) k, Quantity Units No. TYPE BA -6 MIL.PLASTIC BAG <br /> or'7 A 7 F4FT0 T TRUCK-OT'HER WRAP <br /> GENERATOR'S CER7IFI' T10N: I hereby certify that the above named mater{.,is not a hazardous waste as delined by 40 CFR Part 261 or UNITS <br /> any applicable state law,h n property described,classified and pat2kaged,and is in proper condition for transportation according to - P -POUNDS <br /> applicable regulations;AND, waste is a treatment residue of a previously restricted hazardous waste subject to the Land Disposal Y _YARDS <br /> Restrictions,I certify and warr 1 that the waste has been treated in accordance with the requirknerds of 40 CFR Part 268 and is no]onger a W -CUBIC METERS <br /> hazardous waste as defined by 4410 CFR Pan 261. Y3 -CUBIC YARDS <br /> 1 � C�[1ill � � V O -OTHER <br /> Generator Authorized Agent Name Signature -" Shipment Date <br /> TRANSPORTER I TRANSPORTER H <br /> a. Name: fl. 7 - h. Name: <br /> b. Address: r, i. Address: <br /> 1 <br /> c. Driver Name/T ,ide: 3 J.-Driver Name/Title: ____ _. <br /> �. PRYI <br /> INTYPE - PRINTlrYPE •• <br /> d. Phone No.: 0r e. Truck No.: k. Phone No.: I. Truck No.: <br /> f. Vehicle License No-/State: m.Vehicle License NodState: <br /> Acknow t of Receipt of aterials. Acknowledgement of Receipt of Materials. <br /> 9 n. <br /> Driver SlpaturV Shl fent Date Driver Si nature Shi meat Date <br /> F , <br /> ._� 7 Use !Z <br /> c <br /> a. Site Name:_ . Phone No.: <br /> b. Physical Address: d. Mailing Address <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. - <br /> Name of Audi razed Agent Signature Receipt Date <br /> a <br /> a. Operator's'Name: b. Operator's'Phone No.: <br /> c. Operator's'Address: <br /> d. Special Handling Instnictions and additional information: <br /> OPERATOR'S CERTIFICATION: I herebydeclare 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 govemmeM regulations. <br /> e. Operator's"Name&Title: <br /> PdTYpe Operators Signature <br /> Date <br /> f. Name and Address <br /> of Responsible Agengy: <br /> g. ❑ Friable: ❑ Non-friable; ❑ Both %friable %nonfriable <br /> Operatcauefer§to the company which owns,leases,operates,.Lronirols,or supervises the facility being demolished or renovated,or the demolition or innovation operation,or both. <br /> t n !r <br /> REORDER ONLY THROUGHBFIIUARCOCONTRACT r, RETURN TO GENERATOR ® srea <br />