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i .111111011111-HAZARDOU .�PECIAL WASTE A ASBEST� MANIFEST If waste is asbestos waste,complete Sections t,rl,IR and TV. NO. .� If waste is NOT asbestos waste,complete only Sections I,II and III. a. Generator Name:4/ 0 -0 1 G RE L-A l5 N A R Ke 1 b. Generating Location: c. Address G!Q -0 f f SS_t F mPrff` 1� d. Address: C)5— e. Phone No.: -2 Q ho o f. Phone No_: If owner of the generating facility differs from the generator,provide: g. Owner's Name: J /, h. Owner's Phone No.: f V TYPE i. BFI WASTE CODE MA � � f � ER (� Containers DM-METAL DRUM DP-PLASTIC DRUM y B -BAG j. Description of Waste: C r n`€�fl A 1"(101 (Jo S a 1 k. Quanti Units leo. TYPE BA -6 MIL.PLASTIC BAG or E © � T TRUCK O -OTHER WRAP GENERATOR'S CERTIFICATION: f 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,it the waste Is a treatment residue of a previousty 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 266 and is no longer a M' -CUBIC METERS hazardous waste as defined by 40 CFR Part 261. �rY' -CUBIC YARDS J� PA C,,&1169, S 3 O -OTHER Generator Authorized Agent Name Signature - Shipment Date Li TRANSPORTER I TRANSPORTER H a. Name: �' S"eWl�G _ h. Name: b. Address: n��/6_kl• A�N�SUS" C� i. Address: Hp yr�r/s�iP�-_s C34• I y5 45 c. DriverNameTtfe: URht~E_f GRCtAtd-s� j. DriverNameTtle: r PRINTITYPE - PRINTIrYpE d. Phone No.: 7/1 e. Truck No.: �� k. Phone No.: I. Truck No.: j f. Vehicle License No./State: f J I69 47 m.Vehicle License No./State: Acknowledgement of Receipt of Materials. 3 Acknowledgement of Receipt of Materials. Q. Driver Sl na � l ent r7are� n nn.9,sl ature shipment Date . a. Site Name: L J T V A70� R OR•D c. Phone No.: 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 of Autlgdzed Again Signature Rovelpt Oat. a. Operator's'Name: b. Operator's'Phone No.: c. Operator's`Address: d. Special Handling Instructions and additional information: 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, packed,marked,and Mbeled,anti-are in all respects in proper condition for transport by highway according to applicable international and government regulations. e. Operator's'Name&Title: Printrrype Operators Signature Date f. Name and Address of Responsible Agency: g.❑ Friable; ❑ Non-friable; ❑ Both %friable %nonfriable Operatdw rejers to the company which ownsJoases,operates,controls,or supervises the facility being demolished or renovated,or the demolition or renovation operation,or both. REORDER ONLY THROUGH EFI 1 UARCO CONTRACT RETURN TO GENERATOR ® 26o-720e SW