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NON-HAZARDOUS SPECIAL WASTE & ASBESTOS MANIFEST <br /> It waste is asbestos waste, complete Sections I, 11, III and IV No. 779914 <br /> If waste is NOT asbestos waste complete only Sections I, II and III <br /> Section I GENERATOR (Generator completes a"of S2520 <br /> Generator Name �� t E1 b Generating Location <br /> d Address <br /> Address a <br /> Phone No +' ' f ~ f Phone No <br /> f owner of the generating facility differs from the generator, provide <br /> I Owner's Name h Owner's Phone No <br /> TYPE <br /> DM-METAL DRUM <br /> BFI WASTE CODE f �� } f f [ZT_) t( W]1 Containers BBp _S GSTiC DRUM <br /> k Quantit Units No TYPE BA -6 MIL PLASTIC BAG <br /> Description of Waste or WRAP <br /> 1T -TRUCK <br /> r c3 t- L r'I f t ,) y O -OTHER <br /> E? <br /> UNITS <br /> GENERATOR S CERTIFICATION I hereby certify that the above named material Is not a hazardous waste as defined by 40 CFR Part 261 <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,it 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,+n accordance th the requirements of 40 CFR Part 268 and Is no longer M3-CUBIC METERS <br /> Y3 -CUBIC YARDS <br /> a hazardous waste as defined by 40 CFR Part 261 F , O -OTHER <br /> Generator Authorized Ag6fit Name Signature �' �i Shipment Date <br /> SeIS II <br /> Ins 'co"Vie"o 1_9 <br /> TRANSPORM(6Y6TWOtQ[txirrtp'Iaw 24-a 111=1 In GofEet6 a <br /> TRANSPORTERI TRANSPORTER II <br /> h <br /> a Name Name <br /> Address I Address <br /> c Driver Name/Title I PRINTlTYPE Driver NametTitle PRINTITYPE <br /> d Phone No <br /> e Truck No k Phone No I Truck No <br /> f Vehicle License No /State F m Vehicle License No /State <br /> Acknowledgement of Receipt of Materials Acknowledgement of Receipt of Materials <br /> - [:]:::[= n <br /> g <br /> Shipment Date Dmar Signature Shipment Date <br /> Drrvar Signature � - <br /> Section III DESTINATION (Generator completes a-d,destinatwn site cantptetse 6:0 r <br /> c Phone No <br /> a Site Name <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 /> f Signature Receipt Date <br /> of Authorized Agent w <br /> w r <br /> Section IV - ASBESTOS (Generow onrnptete a-d,f.d,operator'=mptsto e4 <br /> a Operator's' Name b Operator's" Phone No <br /> c Operator's` Address <br /> d Special Handling Instructions and additional information <br /> f%0r, ATnA4Q rpaTiFICATION 1 herebv declare that the contents of this consignment are fully and accurately described above by proper shipping name and are classified <br />