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NON-HAZARDOUS SPECIAL WASTE & ASBESTOS MANIFEST <br /> If waste is asbestos waste, complete Sections I, II, III and IV No. 779913 <br /> If waste is NOT asbestos waste, complete only Sections I, II and III <br /> Section I GENERATOR (Generator completes all of Section II ` <br /> a Generator Name b Generating Location <br /> c Address d Address <br /> e Phone No f Phone No <br /> If owner of the generating facility differs from the generator, provide <br /> g Owner's Name h Owner's Phone No <br /> TYPE <br /> I BFI WASTE CODE ; ? DM-METAL DRUM <br /> f ( Containers DP -PLASTIC DRUM <br /> B -BAG <br /> I Description of Waste k uanti units No 1 TYPE BA -B MIL oPL SSTIIC BAG <br /> WRAP <br /> ! • ;- t = - O '" ® [ E O -OTHER <br /> GENERATOR S CERTIFICATION I hereby certify that the above named material is not a hazardous waste as defined by 40 CFR Part 261 UNITS <br /> or any applicable state law,has been properly described classified and packaged,and is in proper condition for transportation according to P -POUNDS <br /> applicable regulations AND,If the waste Is a treatment residue of a previously restricted hazardous waste subject to the Land Disposal Y -YARDS <br /> Restrictions I certify and warrant that the waste has been treated in accordance with the requirements of 40 CFR Part 268 and is no longer Ms-CUBIC METERS <br /> a hazardous waste as defined by 40 CFR Part 261 Y3 -CUBIC YARDS <br /> O -OTHER <br /> ator Authorized Agent Name Signature .j lei Shipment Date <br /> TSAWTRANSPORTER(Gauier�or ransp � fe h== i-,,", " <br /> TRANSPORTER I TRANSPORTER II <br /> a Name h Name <br /> b Address i Address <br /> c Driver Name/Title I Driver NamelTitle <br /> PRINT/TYPE PRINT/TYPE <br /> d Phone No a Truck No k Phone No I Truck No <br /> f Vehicle License No(State m Vehicle License No /State <br /> Acknowledgement of Receipt of Materials Acknowledgement of Receipt of Materials <br /> gn <br /> Driver Signature Shipment Deft Driver Signature Shipment Data w <br /> Section III DESTINATION (Generator comperes ted;destinatrori site ciornpletes i�f) <br /> a Site Name c Phone No <br /> b Physical Address d Mailing Address <br /> e Discrepancy Indication Space <br /> I hereby certify that the above named material has been accepted and to the best of my knowledge the foregoing is true and accurate <br /> fof Au[izo <br /> wnd Agent Signature Receipt Date <br /> Section Iv- iiS�!STOS�_ � <br /> a Operator's' Name b Operator's' Phone No <br /> c Operator's' Address <br /> d Special Handling Instructions and additional intormation <br />