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1 BION-NAZARDOU�PECIAL WASTE A ASBEST� MANIFEST <br /> If wAste is asbestos waste,complete Sections f,]I,TII and IV. wi <br /> It waste is NOT asbestos waste,complete only Sections I,H and III. No. 29,6504 9,650,4 <br /> s�RT <br /> - g <br /> a. Generator Name: 6—J-1ff'I.4/5' A1 74„_„ b. Generating Location: <br /> c. Address a L_ ;OF d. Address: <br /> e. Phone No.:_._:2!0 P C/,,-7/ r,� 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. BFI WASTE CODE ® Containers DM-METAL DRUM <br /> DP -PLASTIC DRUM <br /> A1� j B -BAG <br /> i. Description of Waste: k. Quantity Units No. TYPE ]3A -6 MEL,PLASTIC SAG <br /> or <br /> O .OTHER WRAP <br /> GENERATOR'S CERTIFICATION: I hereby certify that the above named material its not a hazardous waste as defined by 40 CFR Part 261 or UNITS <br /> any applicable state law, has been properly described,classified and packaged,and is in proper condition for transportation according to p -POUNDS <br /> applicable regulations;AND,if the waste is a treatment residue of a previously restricted hazardous waste subject to the Land Disposal Y -YARDS <br /> Restrictions,I certify and warrant that the waste has been treated in accordance with the requirements of 40 CFR Part 2158 and is no longer a M' -CUBIC METERS <br /> hazardous waste as defined by 40 CPR Part 261. r Y' -CUBIC YARDS <br /> �rh ( a C V€II,i,e- — _nth- _ _ O -OTHER_ <br /> Generator Authorized Agent Name Signature Shipment Date <br /> - .._ _ :•rsv- _ - _ w <br /> TRRAANSPORTERI TRANSPORTERII <br /> a. Name: jR6/tL/ <br /> ` .-/n f L'v_nJ dr► Caf�r r h. Name: <br /> b. Address: [ `1 y/GA-/1 Gr/ i. Address: <br /> C11 4,4570 <br /> c. Driver NameTUe:;/ s .G✓t�I�7 _j DAvarNarne/Title: <br /> PRINTITYPE PRIN frYPE <br /> d. Phone No.: 7d U7 lv l r7 �J e. Truck No.: f4 4 '7 k. Phone No.: 1. Truck No-: <br /> f. Vehicle License NoJState: 10;' d 7G G t^ m.Vehicle License NoJState: <br /> Acknowledgement of Receipt of Materials. Acknowledgement of Receipt of Materials. <br /> g. n. <br /> Driver S atwu Shl ent flat. Driver Signature shi ment Date - <br /> Y 1� <br /> a. Site Name: _f � c. 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 Authorined Agent signature Receipt Date <br /> a. Operators'Name: b. Operator's*Phone No.: <br /> c. Operators'Address: <br /> d. Special Handling Instructions and additional information: <br /> OPERATOR'S CERTIFICATION: I hereby declare that the contents at 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 cond€tion for transport by highway according to applicable international and government regulations. <br /> e. Operators*Name&Title: <br /> Printrrype operalora signature - Date <br /> t. Name and Address <br /> of Responsible Agency: <br /> g.❑ Friable; ❑ Non-friable; ❑ Both %friable %nonfriable <br /> " Operator ref@rs to the company which Awns,leases,operates,controls,or supervises the facility being demolished or renovated,or the demolition or renovation operation,or both. <br /> REORDER ONLY THROUGH BFIIUARCOCONTRACT RETURN TO GENERATOR ® 29D-7208 SW <br />