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! NON-HAZARDO"r; SPECIAL WASTE & ASBEE,.0)S MANIFEST If waste is asbestos waste,complete Sections I,II,ISI and W. No.2S G 5 3 4 - 1t waste is NOT asbestos waste,complete only Sections S,U and W. kn a. Generator`�arrle~ R a!S Q�} b. Generating Location. Ic. Address Q j o 4 S S f@ C d. Address: I e. Phone No.: 7—OC1Y — f. Phone No.: it owner of the generating facility differs from the generator,provide: 4 g. Owner's.Name: h. Owner's Phone No.: TME f ,h Containers iners DM-METAL DRWM I V I. BFI WASTE CODE ® � 1� } r DP-PLASTIC DRUM } 9 -SAG j. Description of Waste: C x3114 A(0)N-40 f) 5n 1 t- -_ k, Quantit Units No. TYPE BA 6 MIL.PLASSATIIC BAG or W f M01 ED T -TRUCK O •OTHER I GENERATOR'S CERTIFICATION: I hereby certify that the above named material is not a hazardous waste as defined by 40 CFR Pan 261 or 0 ITS f any applicable state law,has been property described,classified and packaged,and is in proper condition for transportation according to P -POUNDS applicable regulations;AND,it the waste Is a treatment residue of a previously restricted hazardous waste subject to the land Disposal Y -YARDS Restrictions,I canify and warrant that the waste has been treated In accordan a with the requirements of 40 CFR Part 266 and is no longer a M' -CUBIC METERS i haze` rste as defined by 40 CPR Part 261. Y' -CUBIC YARDS 1_J- UOIAlz O OTHER Generator AldYuorizetl Agent NameSignature Shipment Dale v TRANSPORTERS TRANSPORTERII a. Name: aShc` 3� %)j oj,t H47" ¢ Th. me: a- b. Address: ia—� �c fress b. ftar c. Driver NamelTrtl `LC I' INT/rYPE •�� 1• CfrrVerNa7rlP tfe: d. Phone No. Lr e. Truck No.: /Pb� PRrNTrtYPE 6 k. Phone No.: I. Truck No.:�4 + f. Vehicle License No./State: 5 �24� C Acknowledge sof Receipt pf Mate :ars. M. vehicle License NoJState: Fr d Acknowledgement of RecePt of Materials. Ddver to - � n- ;: I merit Date h Dmrer Si nature shipment Date a. Site Name: �. "� 5 C 10 c. Phone No.: b. Physical Address: d. Mailing Address e. Discrepancy Indication Space; I hereby certify that the above named material has been accepted and to the best of my knowledge the foregoing is true and accurate. Name of Authorized Agent SM�nasure neoaipt Date a. Operator's'Name: b. Operator's'Phone No.: c. Operator's'Address: d. Speciaf Handling Instructions and additional information: OPERATOR S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by proper shipping name and are classified, packed,marked,and labeled,and are in all respects in proper condition for transport by highway according to applicable international and government regulations. a. Operator's'Name&Title: o Pdnt type Operators Slgnaano Date Name and Address of Responsible Agency: ❑ 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 both. :ORDER ONLY THROUGHBn UARCO CONTRACT RETURN TO GENERATOR ® 260-7zoassa ISO-7208 S94 f. II Name of Authorized Agent signature (/ r t ° a- Operator's'Name: b. Operator's'Phone No.: c. Operatoes'Address: d. Special Handling Instructions and additional information: OPERATOR'S CERTIFICATION:•I hereby declare that the contents,tjf this consignment are fully and accurately described above by proper shipping name and are classed, packed,marked,and labeled,and are in all respects in proper condition for transport by highway according to applicable intemational and government regulations. e. Operatnr's'Name&Title: Print rype. - Operator's Slgnatuue Date f. Name and Address - of Responsible Agency: g.❑ Friable; ❑ Non-friable; ❑ Both % Table ,.. %nonfriable 4 Operator refers to the company which owns,leases,aperstes,contrar the facility being demolished or renovated,or the demolition or renovation operation,or both. . Far REORDER ONLY THROUGH BFI 1UARCOCONTRACT 4;U`RN TO GENERATOR ® 200-MISsrea . - Y