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1 NON-HAZARDOU,SPECIAL WASTE s s � * I '� & ASBE.,�g MANIFEST If waste is asbestos waste,complete Sections I,II,M and IV If waste is OT ashesfos waste,complete only Sections I;II and III. NO. 29GS36 a. Generator Name: (� M c. Address F R� _ b.,Generating Location: S ve d. Add f ress: 'e. Phone No_ 4 If owner of thegenerating facility differs from the generator,pro vitle: f Phone No.. g. Owner's Name: h. Owner's Phone No.: F i. BFI WASTE CODE Q TYPE 1 Containers DM-METAL DRUM I4 1- 1. Description of Waste: u DP-PLASTIC DRUM r1 ^ 5q B -BAG - k. Quant' units No. TYRE BA - 6 MIL.PLASTIC BAG / �I�-T—�I or WRAP GENERATOR'S CERT1FiCATfON: I hereby candy r /; I i! I T -TRUCK I that the above named material is not a ha t 201 Or O -071-IJ_R any applicable state law,has been Propertyhazardous waste as by 44 CFR Part 201 Or applicabfe regulations;AND,Jr the wastidarfbed,classified and packaged,and Is in NIT atment residue of a proper condition far:transponation accordin to Restrictions,I ce previously restricted hazardous waste subject to the Land Disposal L-YARDS NDS riTs and warrant that the waste has been treated in accordance with the requirements of 40 CFR Part 268 and is no longer a hazardous waste as tlefined bynt CFq Part 261, C METERS /"�Ax_ C YARDSeneratorAuthorfzed A �,5 R Agent Name Signature —• - f- '�`V Shipment Date 3 TRANSPORTERI a: Name: TRANSPORTER II b. Address: ��r � h. Name: 1 r 1. Address: c. Drfvor Name/Title: - P>RiNTrtYPE Dritf Nzfmamtle:: d. Phone No.: 7 PRiNrmPE e. Tnrck'No:: k. Phone No.: I. Vehicle License No./State: 1. Thick No.: Acknowledgement of Receipt of Materials. m.Vehicle License No./State: Acknowledgement of Receipt of'Materials. Driver Si tune �. �� n. jl Shi ate nriver tlire Sh nt Date c. Phone No.: b. Physical Address: 1 d. Mailing Address . i e. Discrepancy Indication Space: I hereby certify that the above named material has been jGcftpN and to the best of my knowledge the foregoing is true and accurate. t Rome rn Aurhormed Agentl 7 rT 6 to Receipt nate Rx a MR a. Operators',Name: b. Operator's'Phone No.: c. Operator's'Address: d. Special Handling Instructions and additional information: O?ERATOR S CERTIFICA710N: 1 hereby declare that the contents of this consignment are fully and accurately descfibed 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 applieatile.intemational and govemment regulations. e. Operator's'Name&Title: f- Name and Address" opererars srgnaw e p of Responsible Agency: g-❑ Friable; ❑ Non-friable; ❑ Both friable 96 nonfriable Operator refers to the company which owns,leases,operates controls,or§uparvises the facility being demolished or renovated,or the demolition or renovation operation,or both. _ REORDER ONLY THROUGH BFi!UARCO CONTRACT RETURN TO GENERATOR ® 260.72DBWN