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i - <br /> NON-HAZARDOUS SPECIAL WASTE & ASBESTOS MANIFEST <br /> r If waste is asbestos waste, complete Sections I, 1I, 111 and IV NO. 779912 <br /> If waste is NOT asbestos waste, complete only Sections I, II and III <br /> ectlon I GENERATOR (Generator comptetes au of Section I) <br /> Generator Name J b Generating Location <br /> Address ' ` d Address , <br /> Phone No ' - f Phone No <br /> owner of the generating facility differs from the generator, provide <br /> Owner's Name h Owner's Phone No <br /> TYPE <br /> 4114�4Y1Containers DM-METAL DRUM <br /> BFI WASTE CODE t.- �� 7 y DP -PLASTIC DRUM <br /> 8 -BAG <br /> Quandt units No TYPE BA -6 MIL PLASTIC BAG <br /> k <br /> Description of Waste or WRAP <br /> T -TRUCK <br /> O -OTHER <br /> UNITS <br /> GENERATOR S CERTIFICATION I hereby certify that the above named material is not a hazardous, <br /> as de nod by 4o CFR Part 261 <br /> o pphcable state law has been properly described classified and packaged and is in proper condition for transportation according to P -POUNDS <br /> le regulations,AND,if the waste Is a treatment residue of a previously restricted hazardous waste subject to the Land Disposal Y YARDS <br /> a�bMs CUBIC METERS <br /> ResTotions,I certify and warrant that the waste has <br /> been treated in accordan a with the requirements of 40 CFR Part 268 and is no longer Y3 CUBIC YARDS <br /> a hazardous waste as defined by 40 CFR Part 261 ` I O -OTHER <br /> Shipment Date <br /> �, <br /> Generator Authorized Agent Name Signature }f / J ! <br /> Transporter[complete e-g ' <br /> 3ef tion II TRANSPORTER(Generator complete 8-d. Transporter n compEate h n) <br /> TRANSPORTER 1 _ TRANSPORTER II <br /> h Name <br /> a Name <br /> Address `' / _ i Address <br /> -1 <br /> Driver Name/Title ' f-,I ' rV n' r`_� ) Driver Name/Title PRINT/TYPE <br /> PRINT!TYPE <br /> d �' <br /> 1- - ; ' e Truck No <br /> Phone No k Phone No I Truck No <br /> Vehicle License No /State f}f es m Vehicle License No /State <br /> Acknowledgement of Receipt of Materials Acknowledgement of Receipt of Materials <br /> ) - f I (i n <br /> Shipment Data Driver Signature Shipment Date <br /> Driver�ignawre <br /> Section III <br /> DESTINATION (Generator completes ltd,destlw=site compli tes.e f) <br /> c Phone No <br /> a Site Name <br /> b Physical Address <br /> d Mailing Address <br /> i <br /> e Discrepancy Indication Space <br /> named material has been accepted and to the best of my knowledge the foregoing is true and accurate <br /> I hereby certify that the above <br /> f Signature Receipt Date <br /> Name of Authorared Agent <br /> $8Cti0l7 TV <br /> b - d �, ASBESTOi c�aar oo�tpioe aim. .trC t t 31 <br />