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NON-HAZARDOU' PECIAL WASTE A ASBESTf' 1 MANIFEST ` <br /> If waste is asbestos waste,complete Sections I,II,III and TV. 28,6 <br /> • if waste is NOTasbestos waste,complete only Sections I,II and tel. No•L <br /> a. Generator Name: b. Generating Location: <br /> c. AddressL41 an EPE d. Address: <br /> --.-- S To Y,A 6 r% � //CA 5152_n 5 <br /> e. Phone No.: (_ 't fD—7100f. Phone No.: <br /> If owner of the generating facility differs from the generator,provide: <br /> g. Owner's Name: h, Owner's Phone No.: <br /> TYPE <br /> i. BFI WASTE CODE 4 5 k651 <br /> Kt/ <br /> [V_k] Containers DM-METAL DRUM <br /> V DP-PLASTIC DRUM <br /> Description o1 Waste: C 0 n+A M B -BAG <br /> j. p j(1�l F�? S O `j j k. Quantity llnirs No. TYPE BA -fi MIL.PLASTIC BAG <br /> + <br /> JC60 M,01 or WRAP <br /> O -OTHER <br /> GENERATOR'S CERTIFICATION: I hereby certify that the above named material is not a hazardous waste as defined by 40 CFR Part 261 or UNITS <br /> 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,if the waste is a treatment residue of a previously restricted hazardous waste subject to the Land Disposal Y -YARDS <br /> Restrictions,i cenlfy and warrant that the waste has been treated in accordance with the requirements of 40 CFR Part 269 and is no longer a M' -CUBIC METERS <br /> hazardous waste as defined by 40 CFR Part 261. Y3 -CUBIC YARDS <br /> t, CV@)i,PL , Li T'} 0 OTHER <br /> Generator Authorized Agent Name Signature SNpmenl Date <br /> 00, k7 <br /> p TRANSPORTER] TRANSPORTERII <br /> a. Name:^ _3� T1'lantk �` h. Name: <br /> to. Address: "Yi. Address: <br /> c Driver NametTitle: j. Driver Name/Title_: f <br /> PRINTrrYPE PRINTMPE _ <br /> d. PhZelfl f•. f,:-2—?Z e. Truck No.: r k. Phone No.: I. Trude No.: <br /> f. Vehicle License NoJStat m.Vehicle License No./State: <br /> Acknowledgement of We&6t 9 f rials. Acknowledgement of Receipt of Materials. <br /> 9. n. <br /> Dever s' fore_ - sni em Dere ❑river S Nre Shl t Date <br /> a. Site Name: 6r—I V?,yc 0 P, a A 6 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 of my knowledge the foregoing is true and accurate. <br /> 1 <br /> f <br /> Name d Auftp ed Agent signature Receipt Date <br /> n — <br /> a. Operator's"Name: b. Operators"Phone No.: <br /> c. Operator's'Address: <br /> d. Special Handling Instructions and additional information: <br /> 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&Title: <br /> PrintrType Operator's Signature Dare <br /> I. Name and Address <br /> of Responsible Agency: <br /> g.❑ Friable; ❑ NOn-friable: ❑ Both %ffiable %nonfdable <br /> ' 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. <br /> REORDER ONLY THROUGH BFI lUARCOCONTRACT RETURN TO GENERATOR ® 260-720D SW <br />