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,3 r NON-HAZARDOiti' SPECIAL•WASTE`A'ASBES�,tS MANIFEST <br /> It waste is asbestos waste,complete Sections I,H,III and IV. <br /> If waste is NOT asbestos waste,complete only Sections I,II and;til. No. , <br /> a. GeneratorNari_tel�M�t1'ulR�J b. Ge eCatingLocation: <br /> { <br /> c. Address 5 tx• d dress; <br /> t7 r <br /> e. Phone No.: / f. Phone No.: <br /> If owner of the generating facility differs from the an tor, rovide: <br /> r <br /> ig. Owner's Name: h. Owner's Phone No.: <br /> TYPE <br /> L BFI WASTE CODEZ� 5 O ' 1'�l I d/ Containers OM-METAL DRUM <br /> a0() , <br /> ✓ DP-PLASTIC DRUM <br /> y B -BAG <br /> J. Description of Waste: � i 501' k. Quart Vrrits No. TYPE BA -6'MIL,PLASTIC BAG <br /> 1 rV1 Ef f[T]. O -OTHERWRAP <br /> f + <br /> GENERATOR'S CERTEFICATiOM 1 hereby certify that the above named material is net a hazardous was[p9 define b 40 CFR rt 261 UNIT <br /> any applicable state law,has been properly described,classified and packaged,and Is in proper con�ilf� rin ming o P -POUNDS <br /> applicable regulations;AND,It the waste is a treatment residue of a previously restricted hazardous waste subia to.the La d Di Y -YARDS <br /> Restrictions,I certify and warrant that the waste has been treated in accordance with the requiremOnts of 40 CFR re <br /> P 68 a is c ir M' -CUBIC METERS <br /> hazardous waste as defined 40 CFR Part 261. <br /> by _ <br /> � Y' CUBIC YARDS , <br /> O -OTHER <br /> Ce014 ( "I � <br /> Generator Authorized Agent Name Signature Shipment Date <br /> i. <br /> r TRANSPORTER] TRANSPORTERTI <br /> a. Nam, F WAA- h. Name: <br /> b. Address: Q L 1 i. Address: <br /> i <br /> .LI g y� <br /> c:•E)rivervNeme/T1tfe:-._. <br /> PRINTFIYPE PRINT/FYPF, <br /> d. Phone No.:_._-73 Z '57711 e. Truck ND.: T k. Phone No.: I. Truck No.: <br /> f. Vehicle License No./Stale:_ „• m.Vehicle License Ni <br /> f Acknowledgement of Receipt of Materials. Acknowledgement of Receipt of Materials. <br /> a g. 0 g 1 n <br /> Driver Si ature Shi menl Date Driver Si atum I <br /> 'Shi ant Date <br /> t a. Site Name: Sia- c. Phone No.: <br /> b. Physical Address: d. Mailing Address <br /> e. Discrepancy Indication Space: <br /> I hereby certify that the above named material has been accepted and to the best oknowledge the foregoing is true and accurate. <br /> f. � 164I . <br /> Name of Authorized Agent Signature ,Reoelpt Data 7 <br /> r a. Operator's'Name: b: Operator's'Phone No.: <br /> c. Operator's`Address: <br /> d. Special Handling Instructions and additional information: <br /> 'I 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, <br /> packed,marked,and labeled,and are in all respects in proper condition for transport by highway according to applicable international and government regulations. <br /> e. Operator's Name k Title: <br /> PdnNrype - operators Srgmtum Date <br /> f. Name and Address <br /> of ResloWsible Agency: ' <br /> g. ❑ Friable, ❑ Non-friable; ❑ Both %friable %nonfriable <br /> Operator refers to the company which owns,teases,operates,controls,or supervises the facility being demolished or renovated,or the demolition or renovation operation,or loth. <br /> is <br /> _ REORDER ONLY THROUGH OR UARCOCONTRACT - `RETURN TOGENERATOR ® 260-72D8&W <br />