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r 7-NON-HAZARWO1"" SPECIALWASTE & ASSESl S MANIFEST If waste is asbestos waste,complete Sections I,II';III and iv. It waste is NOt asbestos waste,complete only Sections I,u' III. No• 2S 652 J I a. Generator Name: GA w b. Generating Location: f d. Address: f S I�,CM�9r+ e. Phone No.: � I. Phone No.: If owner of the generating facility differs from the generator,provide; i g. Owners Nemo: h. Owner's Phone No.: f i. BF]WASTE CODE ® .� &EUaIV KI Containers DM-METAL DRUM DP-PLASTIC DRUM j. Description of Waste: CA 173l�M�n � � S� _ i' B -BAG k. QUanti Units No. TYPE BA -6 MIL.PLASTIC BAG E0 [�M or WRAP T -TRUCK r O -OTHER 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 any applicable state law,has been properly described,classified and packaged,and is in proper condition for iransportation according to P -POUNDS i applicable regulations;AND,if the waste is a treatment residue of a previously restricted hazardous waste subject to the Land Disposal Y -YARDS Restrictions,1 certify and warrant that the waste has been treated in accordance with the requirements of 40 CFR Pan 268 and is no longer a M' -CUBIC METERS hazardous ste as defined by 40 CFR Part 261. r 11 Y3 -CUBIC YARDS 1 O -OTHER i Generator Authoriz 9en1Name Signature �� I Shipment Date a - - _ TRANSP 7 -1 TRANSPORTER a h a. Name- tiff . . Name: , b. Address; i. Address _ t < / -._-C. 120ver NameTtle: PRINT E V J•<Driver Name/Title: , - d. Phone No.: t PRINT/TYPE e. ruck No.: Z�. k. Phone No.: I. Truck No.: q Irl R f, Vehicle License NoJState: m,Vehicle License No./State: Acknowled a nt of ecelpt of Materials. Acknowledgement of Receipt of Materials. i Driver l j i 4 n Sh ent Dates Driver S azure 5 1 Date I ~ 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. r 1. f1 Name of Authorized Agent Signature - -.-;_ Receipt Date IF - { a. Operator's'Name: b.'Operators*Phone No: c. Operator's'Address: d. Special Handling Instructions and additional information: OPERATOR'$CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by proper shipping name and are dassifie.d, packed.marked,and labeled,and are In all respects in proper condition for transport by highway according to,applicable international andovemment g regulations.' e. Operator's`Name&Title: i P*t(Type f. Name and Address operators sgnature oem 'of Responsible Agency; g. ❑,Friable: e Non-triable; ❑ Both NS %friable %nonfriable { Operator refers to the company which owns,leases,operates,controls,or supervises the facility being demolished of renovated,or the demolition oii renovation operation,or both. REORDER ONLY THROUGH BFI I UARCO CONTRACT RETURN TO GENERATOR ® , 'il