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NON-HA=AR60'y i SPECIAL WASTE & ASBE;,w,I,S MANIFEST <br /> 1,111we - <br /> If waste is asbestos waste,complete Sections I,II,III and IV. No-2-9653.0 <br /> If waste is NOT asbestos waste,complete only Sections I,II and III. <br /> a. Generator Name: GA 9 win 1 /VI b.Generating Location: <br /> c. Address S J cl. Address: <br /> e. Phone No.: Caf Q l '0[ 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.: t- <br /> I i. BFl WASTE CODEI I J�j LPA <br /> EKH�R Containers -METAL DRUM <br /> OP.PLASTIC DRUM <br /> B -BAG <br /> j. Description of Waste: C'J!!�G M I'fi }E(? '/ k, quant€ Units No. TYPE BA -6 MIL.PLASTIC BAG <br /> or WRAP <br /> / T -TRUCK <br /> O -OTHER <br /> GENERATOR'S CERTFFICATIDW'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 law,has been properly described,classified and packaged,and is in proper condition for transportation according to p -POUNDS <br /> I applicable regulations;AND,if the waste is a treatment residue of a previously restricted hazardous waste subject to the Land Disposal Y YARDS <br /> hazardous waste as de <br /> [ Restrictions,€certify and warrant that the waste has been eated in accordance with the requirements of 40 CFF Part 268 and is no tonger a M' -CUBIC METERS <br /> €€ fineVy 40 CFR Part 261. Y3 -CUBIC YARDS <br /> EN�VP-1lL9 a a O -OTHER <br /> Generator Authorized Agent Name JSlgrlatur+ �. Shipment Date ' <br /> TRANSPORTER I TRANSPORTER II <br /> a. Name:&Alilrol N� <br /> l h. Name: <br /> b. Address: IS41S r�/z.l� )��, L Address: <br /> c_-brlver Narne/Tdle:GG- i1 p,J <br /> j. -Driver-Name/Title: <br /> / ' PRI e. Tru PRINTr YPE <br /> YPE <br /> d. Phone N ,; +0 e. Truck No. ! . <br /> k. Phone No.; I. Truck No.: {€ <br /> Ill Vehicle License NoJStateVA M.Vehicle License No./State: <br /> Ackno jie gement of Receipt of Materials. Acknowledgement Of Receipt of Materials. <br /> g �v <br /> iSriver Si neNra 'W "' n. <br /> - Shi em Data Driver 5 nligature <br /> Shl at Dxra <br /> ' <br /> a. Site Name. <br /> c. Phone No.; <br /> b. Physical Address: <br /> 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 /> L <br /> Nene al Authpnzad Agen3 <br /> Signature � <br /> MOT 79f <br /> 'Fill 3` <br /> a. OpeMtDe..s"Name: b. Operator's'Phone I <br /> G. Operators"Address: <br /> d. Special Handling Instructions and additional information: <br /> OPERATOR S CE1:: 1 AtIDN: I hereby declare that me 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&Title: <br /> PrintlType <br /> f. Name ancrAddress• operators signalure Data <br /> of Responsible Agency: <br /> g-[] Friable; ❑ Non-friabie; ❑ Both %friable %nontrrable <br /> Operator refers to the company which owns,leases,operates,controls,or supervises tfte facility being demolished or renovated,or the demolition or renovation operation,or both, <br /> REORDER ONLY THROUGH BFI I UARCO CONTRACT€ <br /> RETURN TO GENERATOR ® 260-72M 5M <br />