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NON•HAZARD.OUIPEIAL WAST & ASBEST MANIFEST <br /> a <br /> ..r1f waste is asbesto&waste,complete Sections[,a,III and IV. No-286,505t 7f waste is NOT asbestos waste,complete only Sections I,H and III, <br /> 292 <br /> les <br /> a. Generator Name: J' I b. Generating Location: <br /> c. Address 1 d. Address: <br /> e. Phone No.: W7 f. Phone No.: <br /> It owner of the gengrating facility differs from the generator,provide: <br /> g. Owner's Name: h. Owner's Phone No.: <br /> TYPE <br /> I. BFI WASTE CODE ® / ) l ll/ <br /> l ! Containers DM-METAL DRUM. <br /> OP-PLASTIC DRUM <br /> AG <br /> j.:-Description of Waste: ���y! A/�liifi� W d g 8 <br /> k. Quanti units No. TYPE BA -6 MIL.PLASTIC SAG <br /> or <br /> MO / � T TRUCK <br /> O -OTHER.WRAP, <br /> GENERATOR'S CERTIFICATION: I hereby certify that the above named material Is not a hazardous waste as defined by 40 CFR Part 261 or UNITS <br /> any applicable state law, has heart properly described,classified and packaged,and is in proper oondition 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 266 and is no longer a M' -CUBIC METERS <br /> hazardous waste as defined by 40 CFR Part 261. Y' -CUBIC YARDS <br /> ­77M 77 },5 O •OTHER <br /> Generator Authorized Agent Name Sig/nature Shipment Date <br /> � <br /> TRA`NNSPORTER I TRANSPQR!TER U <br /> a. Name: J"i\ Ah. Name: <br /> b. Address: -5.W11 CL2 114 � �[�3�X I. Address: <br /> l ! cn I <br /> c. Driver NamenjUez__--__ - Fl—�..- �. \-. - <br /> t � .- -. ._ . .. h A?rivewNamefiitte:- - '. <br /> T/TY'E 1 PRINT/TYPEd. Phone.::5 f C�L - 2 7o. Truck No;„��,� k. Phone ND,; I. Truck No.: <br /> I. Vehicle License No./State:T ,4 1A� .7L3 m.Vehicle License No./State: <br /> Acknowledgement of Receipt of Materials. Acknowledgement of Receipt of Materials. <br /> 9• n. <br /> Driver S' alum Sh' ent Data Dnver Signature Shtemart Date <br /> IN 4-In"Wo <br /> a. Site Name F 1A5-ed 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. 5 <br /> Na d Authorized Agent ___ ftnatum Receipt Date <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 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 /> e. Operator's'Name&Title: <br /> Printrryps operators Signature Data <br /> I. Name and Address <br /> of Responsible Agency: <br /> g.❑ Friable; ❑ Non-friable; ❑ Both %friable %nonfriable <br /> Operator raters to the company which owns,leases,operates,controls,or supervises the facility being demolished or renovated,or the demolition or renovation operation,or both. <br /> REORDER ONLY THROUGH BR I UARCO CONTRACT RETURN TO GENERATOR ® 260-7206593 <br />