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i I <br /> 7 NON-HAZARDOV 'SPECIAL WASTE A ASSESS ;$ MANIFEST <br /> If waste is asbestos waste,complete Sections 1,11,III and IV.i °. <br /> - If waste is NOT asbestos waste,complete only Sections I,Us d;III. No.2916522 <br /> er ■« ' <br /> a. Generator Name: j b. Generating; tion: <br /> F �� <br /> c. Address [� o �, dress: , - <br /> n TT 5 � ;i - i <br /> -/ �D A t i ` <br /> e. Phone No.: f. Pq ne N-64 <br /> If owner of the generating facility differs from the generator,providj: <br /> I <br /> g. Owner's Name: IS.Ijvdrier's Phone No.: i <br /> TYPE <br /> I I. BFI WASTE CODE 10 v ) f 9 f 0 L/I <br /> (,5 Containers DM-METAL DRUM a <br /> DP-PLASTIC DRUM <br /> B -BAG �I <br /> j. Description of Waste: <br /> Yk.. Quanti Units . No. TYPE SA -6 MIL-PLASTIC BAG <br /> T TRUCK <br /> MID / <br /> ar WRAP ffil O -OTHER <br /> GENERATOR'S CERTIFICATION: I hereby certify at the named material is not a-hazardous waste as defined by 40 FR Part 267 or UNITS i <br /> any applicable state law, has been properly descn ,efas led and packaged,and is in proper condition for o t n f;i to -POUNDS l <br /> -. <br /> applicable regulations;AND,If the waste Is a tree ant ides of a previously restricted hazardous waste u n e hand Disposal Y� YARDS <br /> Restrictions,I certify and warrant that the waste has thea•{seated in accordance with the requirements of 40 CFR Part n 268 and is no I erpi=a 1,;,��+ IC METERS <br /> hazardous waste as defined by 40 CFR Part 261 r F' T- �IC YARDS <br /> �/j I 7 IT O OTHER <br /> Generator Authorized Agent Name P <br /> Signature Shipment 9 h Ment Date <br /> TRANSPORTERI TRANSPORTERII <br /> a. Name: h. Name: <br /> b. Address: zo 14, <br /> i.' Address: <br /> Eyrwgdveclslamel.Title: . <br /> n PR1NTrfYPE PRINTFrYPE ,I <br /> d. Phone Not; 1 I e. Truck No.: � .kc Phone No.: I. Truck No.: <br /> f. Vehicle License No./State: 'i 64 f rZ _ m.Vehicle License NoJState: <br /> Acknowledgement of cefpt of Materials. Acknowledgement of Receipt of Materials. <br /> g n. 1`1 Ll <br /> Dr{ver tore Sh mem Date Dri,rer Si nature 7Shipmart Date ' <br /> r <br /> a. Site Name: t' iD C. Phone No.: <br /> t <br /> b, Physical Address: d. Mailing Address. i <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 /> f. <br /> Name of Autlwr4ed Agent Slgmtum Rereipr Dates `` <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 8 Ti*; <br /> Prinfl7ype operators Signature Date <br /> f. Name and Address <br /> of Responsible Agency: <br /> g. ❑ Friable; jf] Non-friable; ❑ Both %friable %nonfriable <br /> Operagr 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 /> REO¢1DER ONLY THROUGH BFI!MARCO CONTRACT RETURN TO GENERATOR ® zao-rtoasM <br />