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S -A-' ' VQ4! Ot/ I p r'7HAZA N®I � l= RpOUSPECIAL WASTE & ASBES'[„�;.� MANIFEST � If waste is asbestofs waste,complete Sections I,II,III and IV. If waste Is NOT asbestos waste,complete only Sections L IT and In. No.2-65 0 7 a. Generator Name:. b. Generating Location: c. Address d. Address: ' e. 42A, rG/J e. Phone No.: ZZ/ f. Phone No.: I If owner of the generating facility differs from the generator,provide: g. Owner's Name: h. Owners Phone No.: i. SF[WASTE CODE I(/I f} I j [/ TYPE Containers DM-METAL DRUM DP -PLASTIC DRUM j. Description of Waste: �' Q� ' ® B -SAG k. Otsanti Unna No. TYPE BA -6 MIL.PLASTIC BAG or I © � O -OTHER WRAP ' 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 any applicable state law.has been properly described,classified and packaged,and is in proper condition for transportation according to P -POUNDS applicable regulations;AND,if the waste Is a treatment residue of a Previously restricted hazardous waste subject to the Land Disposal Y -YARDS Restrictions,I certify 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 haze 0us waste as defined by 40 CFR Part 261. Y3 -CUBIC YARDSWV1 CA. - 'tip / -".��. & O -OTHER j Generato Authorized Agent Name Signature' Shipment Gate ,+1, TRANSPORTER] TRANSPORTER 11 4 I a. Name: -�/Y 1r� "- �« .�,I h. Name: b. Address: C: I. Address: c. Driver Name/Titlet_ L i j. Driver Name/Title: PRIN7r YPE PRINT/TYPE - d. Phone No.:X17 7!7 G L�r7�Y!` e. Truck No.: _f/O k. Phone Na.; I. Truck No.: 1. Vehicle License No./State: �3W 7 m.Vehicle License NoJSiate: Acknowledgement of Receipt of Materials. Acknowledgement of Receipt of Materials. gOr. � !� TTI 5 aarre Sh'mern pate Driver Si nature Shipment nate a � a. Site Name: r� R�.ra. c. Phone No.: _r+ b. Physical Address: d. Mailing Address e. Discrepancy Indication Space: I hereby certify that the above named material has been accepted and to the best of my knowledge the foregoing is true and accurate. Name or Authorized Agent Signature L Receipt Data a. Operator's'Name: a b. pperaloTs'Phone No.: c. Operator's"Address: d. Special Handling Instructions and additional Information:- OPERATOR'S nformationsOPERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by proper shipping name and are classified, packed,marked,and labeled,and are in all respects in proper condition for transport by highway according to applicable international and government regulations. a. Operator's'Name&Title: PhntRype f. Name and Address Operators Signature Date of Responsible Agency: g. ❑ Friable; ❑ Non-friable; ❑ Both %friable %nonfriable Operator refers to the company which owns,fames,operates,controls,or supervises the facility being demolished or renovated,or the demolition or renovation operation,or both. _ I REORDER ONLY THROUGH BEI JUARCOCONTRACT RETURN TOGENERATOR - ® 2so-72aBsie3 ' - - f