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' 4 4 NON-HAZARDO . SPECIAL WASTE & ASBE!,il MANIFEST If waste is asbestos waste,complete Sections I,n,rg acid IV. w, - If waste is NOT asbestos waste,complete only Sections I,H and III. rho..2,91:528 a. Generator Name: 1 �1/ b. Generating Location: c. Address R j Y[ ItfOh S J d. Address: / e. Phone No.: if owner of the generating facility differs from the generator,provide: j g. Owner's Name; h. Owner's Phone No.:" j if. HFI WASTE CODE j �/ (� ! j� TYPE M( 4 t/ 1 I. t Containers DM-METAL DRUM EMDP-PLASTIC DRUM j. Description of Waste: A H r u: f k. QuantiH -BAG Units No. TYPE BA -6 MIL.PLASTIC BAG ' or WRAP j j Q T -TRUCK � O -OTHER GENERATOR'S CERTIFICATION: I hereby certify that the above named material is not a''hazardous waste as defined by 4o CFR Part 261 or UNITS - i any applicable state Taw,has been properly described,classified and packaged,and iso in proper condition fon transportation according to P -POUNDS 'applicable regulations;AND,If the waste is a treatment residue of a previously restricted hazardous waste'subject to the Land Oisposal Y -YARDS t Restrictions,I certify and ftrrant that the waste has been treated in accordance with the requirements of 40 CFR Part 268 and is no longer a hazardous waste as defined by 4D CFR Part 261. 9 M' -CU131C METERS t4 ; 0 CUBIC YARDSck4 sf,{ �.,fei� - o -OTHER i Generator Authorized Agent Name Signature -Shipment Dale _ TRANSPORTERI TRANSPORTER II • a. Name: _ _ [_1/v1 f) h. Name: i j b. Addressg_- y � C' j i. Address: y-2 c. Driver NamelTrtfe: . [ �^ PgllvrrryPeDrfverName/Titte:d.411D+�f : 'i^`�) � / PRINinYPE e. Truck N / k. Phone Ni I. Truck No.: Ii f. Vehicle License No./S. Z r m.Vehicle License No./State: T� f Acknowledgement of R ei to afs. Acknowiedgemerit of Receipt of Materials.s - j ` DrrySi Shi mend Dale Driver si atum - sh crit Date _. _... _.. a• Site Name: F.I d f r d o,t .^ c. Phone No.: - b. Physical Address; d. Mailing Address ;e. Discrepancy Indication Space: i I hereby certify that the above named material has been accepted and to the best of my knowledge the foregoing is true and accurate. ' j Name of Authorized Agent Skj nature - i Receipt Date a. Operatoris'Name: b Operator's'Phone No.: C. Operator's'Address: d. Special Handling Instructions and additional Information:OPERATOR- S GXH I IFICATION. I hereby declare that dile contents of this consignment are fully and accurately described above by proper shipping name and are dasWed; packed,marked,and labeled,and are in aff respects in proper condition for transport by highway according to applicable international and governmentregulations. e. Operator's'Name i Tfde: . Operators Sgnattira ' #. Name and Address note r of Responsible Agency; t 9.❑ Friable; ❑ Non-friable; ❑ Both %friable %nonfriable I Operator refers to the company which owns,leases,operates,controls,or supervises the facility being demolished or renovated,or the demotwon or renovation operation,or both. I REORDER ONLY THROUGH eFIiuARcoCONTRACT RETURN TO GENERATOR ® zeo-Tzoe�