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1 NON-HAZARDOIJ.W PECIAL WASTE & ASBESTU MANIFEST IWaste is asbestos waste,complete Sections f,II,III and IV; NQ.s�,�6 51O p kf waste is NOT asbestos waste,compietevnly Sections 1,13 and III. ��1 G D Com. 'r• I a. Generator Name: b. Generati Location: ` c. Address WC, A Addres ' I e. Phone No.: f. hone No.: If owner of the generating facility differs from the generat r,p vide: . g. Owner's Name: h. Owner's Phone No.: r TYPE a i� I�'}} g Containers DM-METAL DRUM k. BFI WASTE CODE DP-PLASTIC DRUM 13 -BAG j. Description of Waste: COn M I k. Quantity Units I No. TYPE BA -B MIL,PLASTIC SAG 7 -TRUCKorWRAP' - I O OTHER GENERATOR'S CERTIFICATION: I he ify that the abovo,named material Is not a hazardous wast4de ferred 40 CFR P 261 0 UNITS arty applicable state law,has been properly described,classified and`15ackaged,and is in proper condi r t 's ceding P -POUNDS applicable regulations;AND,if the waste is a treatment residue of a previously restricted hazardous 1 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 a 66 and is o to r M' -CUBIC METERS j hazard to as defined by 40 CFR Part 261. - ��14 Y3 -CU131C YARDS ` fI O g /15 14 O -OTHER V GeneratorAuthorized Agent Name Signature Shipment Date - TRANSPORTER I TRANSPORTER H a. Name: T)' � nn h. Name: b. Address: b- 1 i. Address: i: Drs�er ambfntle? t j.-'Driver Namemtle. n (] 14TITYPE PRINT/TYPE d. P44AZ? O S 7 e. Truck No.: k..Phone No.: I. Truck No.: L Vehicle License No-/State: m.Vehicle License NolState:, Acknowledgement of Re l of Mated Is. Acknowledgement of Receipt of Materiais. g. n. € Ori+rar 51 Sh maht Hate !Driver 6 Lure Shi ment Date - a. Site Name: 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. I. Name of Autlwrized Agent Wowture Receipt Date - 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 labeled,and are in all respects in proper condition for transport by highway according to applicable international and government regulations. e. Operator's`Name&Tithe: '•a r f. A p�/ry� OperaWr Signature Date f. Name and Address of Respongble Agency: g.❑ Friable; ❑ Nan-friable; ❑ Both %friable %nonfriable Operator refers to the company which owns,leases,operates,controls,or supervises the facility being demolished or renovated,or the demolition or renovation operation,or both. REORDER ONLY THROUGH BFI I UARCO CONTRACT ® 260-7206 5/83 RETURN TO GENERATOR • i r