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r <br /> NON-HAZARDOU- SPECIAL WASTE & ASBES` S MANIFEST <br /> Ifwaste is asbestos waste,complete Sections 1,I1,III and Iv. NO. Le� 3 <br /> If waste Is NOT asbestos waste,complete only Sections I,II and M. <br /> a. Generator Name:� QwA�5 A tR Ki Q T D. Generating Location: <br /> c. Address A4 a,ef� rt I d. Address: <br /> S or K 4,,„J52`aS <br /> e. Phone No.: 4 W I d f. 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 ! ( Containers DM-METAL M <br /> 7 DP -PLASTIC DRUM <br /> 8 -BAG <br /> j. Description of Waste: C n 1 7 t 501”) k. Quantity Units No. TYPE BA-6 MIL.PLASTIC BAG <br /> or[ZO ) � O TRUCK OTHER WRAP <br /> GENERATOR'S CERTIPICATION: 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 taw,has been property 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 prevleusly restricted hazardous waste subject to the Land Disposal Y -YARDS <br /> Restrictions,I certify and warrant that the waste has been treated in accordance with the requirements of 40 GFR Part 268 and is no longer a M° -CUBIC METERS <br /> hazardous(�7�A us waste as defined!by 40 CFR Part 261. Y3 -CUBIC YARDS <br /> CVf 114& j {I O OTHER <br /> Generator Authorized Agent Name Signature Shipment Date <br /> ' .►ad �?� `.�' -r�:c. --� �� - - >-.--M-..,: mac.-•.-._ <br /> TRANSPORTER I TRANSPORTER H <br /> a. Name: h. Name: <br /> b. Address: C42LLQ i. Address: i <br /> c. Driver NarnerTtle: �r C t2/ j. Driver NdmelTtle: <br /> �Pairrrmre PRINTTYPE <br /> d. Phone e. Truck No.: k. Phone No.: I. Truck No.: <br /> f. Vehicle cense No./State: L ? m.Vehicle License No./State: <br /> Acknow ement of R9cel�Materials. Acknowledgement of Receipt of Materials. <br /> r - <br /> 9- n. <br /> nfirer S-netir2 Shi nt Dat Driver Si nature Sh'merit Oate <br /> a. Site Name: 5 0 p _ 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 /> f. 1 <br /> mama of Aad"b*d Agent signature Rear nate <br /> 4 <br /> a. Operators'Name: b. Operator's'Phone No.: <br /> c. Operator's'Address: <br /> d. Special Handling instructions and additional information: <br /> OPERATOR'S CERTIFICATION: I hereby declare that the conttts 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 con tion for transport by highway according to applicable intemational and government regulations. <br /> e. Operator's'Name&Title: <br /> Pnnvrype operator's signature Data <br /> f. Name and Address <br /> of Responsible Agency: <br /> g.❑ Friable; ❑ Non-friable' ❑ Both %friable %nonfriable <br /> Operator refers to the company which owns,leases,operates,controls,or supervises the faelltty being demolished or renovated,or the demolition or renovation operation,or both. <br /> REORDER ONLY THROUGH BFI I UARCO CONTRACT RETURN TO GENERATOR ® 260-720B SM <br />