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NON-HAZARD SPECIALWASTE & ASBE4Z,,.?S MANIFEST <br /> I If waste is asbestos waste,complete'Sections I,ti,III and IV. <br /> i If waste is W1 asbestos waste,complete only Sections t,II and III. No-29,6531 <br /> . <br /> E � ...e <br /> E _ <br /> 13 <br /> a. Generator Name: — b..Generating Location: <br /> 4 <br /> c. Address l n Q_�„ � K n/h� <br /> I d. Address: <br /> 0 lin <br /> e. Phone No.: 'Z r,_ <� � / C) f.' Phone No.: <br /> F If owner of the generating facility differs from the generator,provide: <br />' g. Owner's Name: h. Ownet's Phone No.: <br /> 1 i. BFI WASTE CODEDLEE <br /> ! &ETR� L <br /> MCA ! � Containers DTVI-METAL DRUM <br /> I .. DP-BLASTIC DRUM <br /> j. Description of Waste: Q_n <7l1n A T, sof k.911� <br /> Units No. TYPE BA -6 MIL.PLASTIC BAG <br /> or WRAP <br /> E M <br /> T -TRUCK <br /> I O -OTHER <br /> GENERATOR'S CERTIFICATION: i hereb certify rtffy that the above named material is net 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 rs lin proper condition for transportation according to P -POUNDS <br /> t applicable regulations;AND,if the waste is a treatment residue of a previousty restricted hazardous waste subject to the land Disposal Y -YARDS <br /> i Reslrictlens,I certify and warrant that the waste has been treated in acoordanca with the requiremenu of 40 CFP Part 266 and is no longer a M' -CUBIC METERShazardous waste as defined by 40 CFA Part 261. <br /> Ya CUBIC YARDS <br /> C„¢11A �,`�,I�/'� SS O -OTHER <br /> Generator Authorized Agent Name <br /> Signa Nre <br /> .tShipment Date , <br /> 2 <br /> TRANSPORTERI u TRANSPORTERII <br /> a. Name:_ �?grtC1trsc It. Name: <br /> It. Address: �i �/ rl( /7p� i. Address: <br /> c. Driver Name/Title: �;;l. e'p fl S w F <br /> j. Driver Namef itle: W <br /> PRINTITTPE <br /> d, Phone li 7y PRINTri <br /> e. Truck No.: k. Phone No.: I. Truck Ne.: <br /> f. Vehicle License NodState: Z'< 7(in <br /> Acknowledgement of Receipt of Materials. m.Vehicle License t o <br /> Acknowledgementnt of of Receipt of Materials. <br /> g- &_)10� 7 <br /> i' Drhrer banal n• - <br /> Shi marl Dere -,Driver Si nature <br /> 4 Shi t Date <br /> a. Site Name: T Phone Ni <br /> b <br /> s b. Physical Address: d. Mailing Address <br /> e'. Discrepancy Indication Space: <br /> LII hereby certify that the above named material has been accepted and to the best of m wledge the foregoing is true and accurate. <br /> i Name at Authorized Agenl Signature <br /> 4 Reoelpl Date <br /> t � a <br /> f i p <br /> ` a. Operator's'Name:` b. Operator's"Phare No.: <br /> c. Operator's'Address: <br /> d. Speclal Handling Instructions and additional information: <br /> OPERATOR S CERT7FlCilli TiON: 1 hereby declare that the 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 andovemmern <br /> 9 regulations. <br /> e: Operator's'Name&Title: i <br /> . - PrhWrype Operators signature <br /> f.'Name and Address Date <br /> of Responsible Agency: <br /> g. ❑ Friable; ❑ Non-fnabie;. ❑ Both %friable <br /> %nonfriable <br /> `r <br /> s Operator refers to the company which awns,leases,operates,controls,or supervises the facility being demolished or renovated,or the do libon or renovation Peration,or troth. <br /> REORDER ONLY THROUGH BFI!UARCO CONTRACT <br /> ' RETURN TO GENERATOR ®,zeormesrsa <br />