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IV6N-HAZARDO' r iPEC1AL WASTE $ ASBEST i MANIFiST 90._� ' a� f if waste is asbestos waste,complete Sections 1,11,TTI arkd IV" ` If waste is NO-2,96-537 ,�asbestos waste,complete only Sections t;II and III. a. Generator Name: S"INA 15 NA A K k b. Generating LocaLon: c. Address F --A 5'1 FA�_M c y7R t d. Address. �c n 52aj e. Phone No.; L �/ f !. Phone No.: It owner of the generating facility differs from the generator,provide: g. Owner's Name: h. Owners Phone No.: i. BFI WASTE-CODE1 TYPE f 1 FIRE] Containers DM-METAL DRUM DP-PLASTIC DRUM j- Description of Waste: C Q✓1- Y9 col L6 A 7,c 10 5 n f� k. Quant i units No. TYPE BA -&MIL-PLASTIC BAG rT TRUCK O -OTHER WRAP GENERATOR'S CERTIFICATION:-i hereby certify that the above named material is not a hazardous waste as defined by 40 CFR Part 261 or UNITS any applicable state law,has been properly described,classified and packaged,and is in proper condition for transportation according 10L(YM), -POUNDS applicable regulations;AND,If the waste is a treatment residue of a previously restricted hazardous waste subject to the Land Disposal -YARDS Restrictions,I certify arid-warrant that the waste has been treated in accordance with the requirements of 40 CFR Part 268 and is no longer a -CUBIC hIETERShazardous waste as defined by 40 CFR Part 261. CUBIC YARDS C U1 J1Aj1(, / G j (I (�, fr OTHER Generator Authorized Agan[Name Signature Shipment Date (/ A. TRANSPORTERy,I TRANSPORTERII a. Name: -T-TV C_f I' h. Name: b Address: 1. Address: c. OriverName>Ttle: lNt i ",A r j. 'DriverName/Title: — t PRINTMPE pRINT/TVPE f d. Phone No.: �} e. Truck No.: Ck. Phone No.: i. Truck No.: I. Vehicle License NoJState: 1�. )- m.Vehicle License No-/State: 4 Acknowled ent of Receipt of Materials. Acknowledgement of Receipt of Materials. D _ Shl nt nate Driver S! Pure rte, Sat ent Date a. Site Name: 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- f. � Name of Authorized Agent stgnature 61Z ReoWFA Date 3' a. Operator's"Name: b. Operators'Phone No.: C. Operator's'Address:- 2 k d. Special Handling Instructions and additional information: OPERATOR'S CERTIFICATION:.I hereby declare that the oontents.af 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 appfrcable international and government regulations. e. Operator's'Name&-Titre: PrirttlrYpe - - �. Operator's Signature pate. f- Name and Address of Responslllp Agency: y T g.❑ Friable; ❑ Non-friable; ❑ Both % iable _ %nonfriable s Operator refers to Me company which owns,leases,operates,can kit . the facility being demolished or renovated,or the demolition or renovation operation,or both. N. REORDER ONLY THROUGH BFI/UARCOCONTRACT RETURNTOGENMATOR ® 200-72MS t