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NON-WAZAR©G -'S SPECIAL WASTE t& ASBE1 <br /> ., OS,MANIFEST <br /> It waste Is asbestos waste,complete Sections 1,11,III and IV. <br /> w If waste lis NOT waste <br /> waste,complete only actions t,II and 11I. N o• 2 S S 5 2 p <br /> a. Generator Name: b. G Gratin tion: <br /> c. Address $ o n tt ,S q d. ss <br /> Io.: _ <br /> e. Phone No.: "1 Y 07—— f. Phone N <br /> / / <br /> If owner of the generating facility differs from the gene tor,provide: <br /> g- Owners Name: h. Owner's Phone No::c <br /> f, <br /> I. BFI WASTE CODE. (1 C t 4 {] (� TYPE <br /> J ! J ! Containers DM-METAL DRUM <br /> AP-PLASTIC DRUM <br /> j. Description of Waste: - k. Ouanti Units No. TYPE BA -6 MIL PLASTIC BAG <br /> or WAAP <br /> T -TRUCK <br /> ® - <br /> GENERATOR'S CERTIFICATION: I hereby certifyO OTHER <br /> that the above named materiaf is not a hazardous a as defined by q0 CFR rt 261 or UNITS <br />{ any app{lcable state law,has been.properly described,classified and packaged,and is in proper tie f <br /> 4 applicable regulations;AND,it the waste is a tieatrnent residue of a previously reatrlEted haze ,,�,n le a g a) Lcym)` -POUNDS <br /> t "su 1act Land to -YARDS <br /> i Restrictions,I certify and warrant that the waste has been treated in accordance with the requirements of CF a <br /> ous waste as defined by 40 CFR Part 261. r1/2�+Pdr?sro go r a -CUBIC METERS <br /> C,,e IlR (••` `! CUBIC YARDS <br /> P f ¢ OTHER <br /> Generator Authorized Agent Name Signature _ CS I (J . <br /> I F Shipman Date - - <br /> —' <br /> TRANSPORTER I TRANSPORTER II <br />$ a. Name: y <br /> h. Name: <br /> b. Address: c <br /> i. Address: <br /> t � <br /> c. Driver Namie7Tltle: <br /> priver Nametfe <br /> PftINTnYPE <br /> d. Phone No.: e. Truck No.:..�(� T PRINTrrYPE <br /> k - <br /> . Phone No.: 1. Truck NII <br /> f. Vehicle License NoJState: <br /> jAcknowledgement of Receipt of Materials. M.Vehicle License NoJState: <br /> Acknowledgement of Receipt of Materials. <br /> 'II 5/k /♦ Q <br /> 1_ I g Diver Sl Aattr <br /> - <br /> �� <br /> a. Site Name:_la� <br /> 1c. Phone No.: <br /> b. Physical Address: <br /> d. Mailing Address <br /> e. Discrepancy Indication Space: <br /> 1 hereby certify that the above named.material has been accepted and to he f my knowledge tha foregoing is true and accurate. <br /> I Name of A+Mprized Agent Signature <br /> # LIL We <br /> j a. Operators"Name: b.Operators'Phone No.; <br /> c. Operators'Address: <br /> t d. Special Handling Instructions and additional information: <br /> 9 O cked,mire ,and lFlCAT,an I hereby declare that the contents of this consignment ere fully and accurately described above by proper shipping name and are cfassffied, <br /> f packed,marked,and labeled,and are in all respects in proper condition for transport by highway according to applicable international and <br /> l government regulations. <br /> e. Operator s"Name&rifle: <br /> i PrinNType <br /> f. Name and Address oparamrs Signature cafe <br /> Of Resp6Slsib4 A&ncy; <br /> { 9! ❑ Friable; Nan-friable; ❑ Both %friable <br /> %nonfriable <br /> I Operator refers to the company which owns,leases,operates,li controls,or supervises the facility being demolished or renovated,or the demolition or renovation operation,or both. <br /> REORDER ONLY THROUGH OR!UARCO CONTRACT <br /> RETURN TO GENERATOR ® zeo-rsKxs <br />