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t - I <br /> . NON-HAZAJ k.,1 'SPECIAL'- WASTE & ASBE S MANIFEST- <br /> If waste is asbestos waste,complete Sections I,II,in and tv. <br /> If waste is Nom,'[asbestos waste,complete only Sections I,II and III, No, 296514 — <br /> t � ' <br /> t� i <br /> a. Generator Name: A 1 b. Generating Location: <br /> G. Address JQ 0 t �FR�fyzCafa d. Address: <br /> e. Phone No.: . <br /> Phone Na.: <br /> If owner of the generating facility differs from the generator,provide: <br /> g. Owner's Name: <br /> h. Owner's Phone No.; <br /> J i. BFI WASTE GODE { , �'� TYPE <br /> : Containers DM-,METAL DRUM <br /> F 4� DP-PLASTIC DRUM <br /> tion of Waste: <br /> P <br /> t <br /> j. Description _ ��rJ� M/n 79 !�Q 5n d ^k,'QuantiUnits - No. TYPE BA -,6 MIL.PLASTIC BAG <br /> ! or <br /> WAAP <br /> . <br /> T -TRUCK <br />! D -OTHER <br />! GENERATOR'S CERTIFICATION: I heretry certify that the above named material is not a hazardaus waste.as defined by 41)GFR Part 261 or UNITS <br /> I <br /> any applicable state law,has been properly described,classdied and packaged,and is in proper condition for transportation accord-rng 10 pPOUNDS <br /> Ip applicable regulations:AND,if the waste is a treatment residue of a praviousty restricted hazardous waste subject to the Land Disposal Y -YARD$ <br /> A hazardous <br /> !certify and warrant that the waste has been treated in accordance with the requirements of 40 CFR Part ma and is no longer-a M' -'CUBIC METERS <br /> hazardous waste as defined by 40 CFR Part 261. �� <br /> �^ r �7 <br /> jy3 -CUBIC YARDS <br /> OTHER <br /> Genera or Authodzed Agent Name Signature - . - <br /> Shipment Date <br /> TRANSPORTER I TRANSPORTERIT <br /> a. Name: r h. Name: <br /> , <br /> b. Address: <br /> I. Address: - <br /> c„ Dmrer.NameLTftla.. {. <br /> i INrrrvae. rw- .j: Driver NamelTitle: <br /> d. Phoniik.• e. Truck No.: FRI . <br /> k. Phone No.: I. Truck No.: <br /> f. Vehicle License NoJState: <br /> m.Vehicle License No./State: <br /> Ackno t: <br /> ement of R <br /> d9 . Receipt f Materials, <br /> p enols• Acknowledgement of Receipt of Materials- <br /> 9- <br /> 1) Si n 7 -1 n. . <br /> v Shi ant Date Driver Si nature d <br /> ' SAMent Data - <br /> it a. Site Name: — S co AO <br /> c. Phone No.: <br /> b. Physical Address; d. Mailing Address <br /> 1 <br /> e. Discrepancy Indication Space: <br /> 1 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 Auttwnzey 1t Signature - <br /> J Receipt Data <br /> a. Operators'Name: b.'Operator's'Phone No.: <br /> c. Operator's'Address: <br /> d. Special Handling Instructions and additional information: <br /> Of>EgATOR S CERTIFICgTIOM: I hereby declare that the contents of this consignment are tally 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 appiictible international and government regulations. <br /> ' e. Operator's'Name&Title: <br /> Pnnflrype <br /> t. Name and Address ow—ra&g-°"_ Data <br /> of Responsible Agency: <br /> 9.❑ Friable; ❑ Non-frtabie; ❑ Both <br /> %friable %nonfriable <br /> �k Otssrata refers to the corn � <br /> i 6 parry which owns,Ieaselt,operates.controls,or supervises the facility being demolished or renovated,or the demolition or renovation operation,or bath. <br /> li <br /> REORDER ONLY THROUGH BFI!UARCO CONTRACT <br /> RETURN TO GENERATOR ® ?60-,2M5&3 <br />