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N0hW*iARD0. ► SPECIAL WASTE $I ASBE,,.�)S MANIFEST <br /> If waste is asbestos waste,complete Sections t,II,III and IV. �+` <br /> If waste is NytZT asbestos waste,complete only Sections i,11 and III. No•28 X 515 <br /> a. Generator Name: k w b: Generating Location: <br /> c. Address IE 'i <br /> P d. Address: "`.: Z `7 <br /> s e. Phone Nc.: <br />{ f. Phone I <br /> I If owner of the generating facility differs from the generator,provide: <br /> g. Owner's Name: <br /> h. Owner's Phone ND.: <br /> I. BFI WASTE CODEI TYPE <br /> Containers DM-(METAL DRUM <br /> DP-PLASTIC DRUM <br /> }. Description of Waste: C 1 61 ! k. Ouanti unffs' No. TYPE BA-6 MIL:PLASTIC BAG <br /> y t or WRAP <br /> T TRUCK <br /> Q -OTHER <br /> GENERATOR'S CERTIFICATION: I hereby ceftity that the above named material is not a hazardous waste as defined by 40 CFR Part 261 or NITS <br /> 1 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,R the waste is a treatment residue of a previously restricted hazardous waste subject!to the Land Disposal Y _POUN <br /> Restrictions,I certify and warrant that the waste has been treated in accordance with thYARDS <br /> e requirements of 40 CFR Part 2fi8 and is no longer a - M' -CUBIC METERS <br /> hazardous waste as defined by 40 CFR Part 261. <br /> Y' -CUBIC YARDS <br /> 1 i jA 1 ti ^r _! O OTHER <br />{ .l <br /> Generator Authorized Agent Name Signature - - - <br /> Shipment Date <br /> TRANSPORTERITRANSPORTERfI <br /> a. Name: N f v fr/4-�V/i deter r h / <br /> h..Name: <br /> b. Address:. <br /> j is Address: <br /> i <br /> c. Driver Namemtle: -+ <br /> j. Driver Name/Title: <br /> f PRINTrrYPE <br /> d. Phone No.: -/,)7 f/7 y' e. Truck Truck No.:/. 7 k. Phone No.: <br /> I. Truck No.: <br /> f. Vehicle License No./State: 7 d <br /> Acknowledgement of Receipt of Materials. in.Vehicle License NaJState: <br /> Acknowledgement of Receipt of Materials. `> <br /> g. <br /> prtrer Si lure n.' ,i ! <br /> F 5' errt pate )pmrer 5,nature <br /> a. Site Name: <br /> c. Phone No.: <br /> F b. Physical Address: d. Mailing Address <br /> i <br /> i <br /> e. Discrepancy Indication Space: <br /> I hereby certify that the above named material has been accept d to the best of my knowledge the foregoing is true and accurate. <br /> t Name of Authorised Agent Signature <br /> U.-pa 'te <br /> a. Operators'Name: <br /> b.i'Operatoes'Phone No.: <br /> c. Operators'Address: " <br /> d. Special Handling Instructions and additional information: <br /> s OPERATOR'S CERTIFICA710N: I hereby declare that Ill a contents of this consignment are fully and accurately described aboveror shipping <br /> packed,marked,and labeled,and are in all respects in proper condition for transport by highway according to applicable international and governmename and nt ent regu ations. aro classified <br /> o. Operator's`Name&Tide: <br /> PrintiType - - <br /> f. Name and Address opemrura sig at°re Date <br /> of Responsible Agency: <br /> g. ❑ Friable; ❑ Non-friable; ❑ Both %friable %nortriable <br /> ,I Or)arall",Tejsrs to the company which owns,leases,operates,controls,or supervises the facility being demolished Of renovated,or the demolition or renovation operation,or both. <br /> REORDER ONLY THROUGH BFI!UAII CONTRACT <br /> REfURN.TOGENERATOR <br /> -- - _ ® 2e0-720e yes <br />