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NON-H �- { AZARDO ► SPECIAL.'.WASTE & ASBE�.- � S i E.,? MANIFEST If waste is asbestos waste,complete f if Sections i,u,[IIwaste isTsestos and IV. waste,compreteonly Sections 1,11 and III- No.23-6-533 a. Genet'�ftrii'tVame: r�C�w �� ' b. Generating Location: c. Address g f;,Yuorf �.5' 9 d. Address; Sir f.'j C e. Phone No.: r S y b '� - /arJ L If owner of the I. Phone No.: generating ratln f ' 9 g acrk differs rs from the generator,provide: g. Owner's Name: h- Owner's Phone No.: I. BFI WASTE CODE C �r T YPE Containers DM-METAL DRUM j. Description of Waste: k. Qu Units BF-BLASTIC DRUM B No. . TYPE BA -6 MIL.PLASTIC BAG J WRAP I T -TRUCK ` GENCRATOR'S CERTIFICATION: I hereby certify that the above named material is not a hazardous waste as O OTHER. any applicable state law,has been properly described,classified and packaged,and is in proper condition for tra sport d'on accordin y for )T applicable regulations;AND,N the waste Is a treatment residue of a previously restricted hazardous wast08 ubject to the Land Disposal Y _yqR _ II Restrictions,I certify and warrant that the waste has been treated in accordance with the requirements of 40 CFA Part 26B and is no longer a Y P491 hazardoy waste as defined by 40 CFR Part 2fi1. _CU81Iq�TEf3Sr'. Ya -CUBIC YARDS O -OTHER Generatpr Authorized Agent Name Signature . l Shipment Data TRANSPORTER I -. -tg'b�'."-"�-_ • _` TRANSPORTER11 a. Name: h- Name: I Address: i. Address: G. Driver Name/Title: -rl-- A-ll PRIIvT/IYPE —� 1. Driller Name/Title: d. Phone Na-: 7 5 e. Truck No.: �` PRitvimPe Ph k. one No.: I. Truck Na.: I, Vehicle edge enNo.t of � m.Vehicle License NOJState: Acknowledgement of Receipt Of Materials. Acknowledgement of Receipt of Materials: . � }Shi aril Date - Dtiver 51 nature st,i n<�ate . c. Phone No.: h. Physical Address: it d. Mailing Address ;I e. Discrepancy Indication Space: I hereby certify that the above named material has been accepted and to the best knowledge the foregoing is true and accurate. IName of Authorized Agent Signature -�?' - r- Receipt Datea. Operato : b. Operator's"Phone No.: c. Operator's'Address: d. Special Handling Instructions and additional information: OPERATOR S CERTlFtCATION: I hereby declare that the contents of this consignment are fully and acarrately described above by proper shipping name andaredasstFred, packed,marked,and labeled,and are in all Tespacts in proper condition for transport by highwaylaccordin to I g applicable international and government regulations. e- Operator's'Name&Tri PrintfType I, Name and Address cpBf91prs ""B Date II of Responsible Agency., 9. ❑ Friable; ❑ Non-friable; ❑ 'Both`^ %friable %nonfriable ` Operator refers to the company which owns,leases,operates,controls,or supervises the facility-being demolished or renovated,.or the demolition or renovation operation,or Moth. - REORDER ONLY THROUGH I 1 UARGO CONTRACT RETURN TO GENERATOR /