Laserfiche WebLink
f. <br /> NON-HAZARDOUS SPECIAL WASTE & ASBESTOS MANIFEST <br /> Ifwaste Is asbestos waste complete Sections I, It, III and IV No. 779935 <br /> If waste is NOT asbestos waste, complete only Sections 1, 1I and III <br /> Section I- GENERATOR (Generator completes all at Section II <br /> a Generator Name ' - V y b Generating Location 'r <br /> c Address d Address <br /> J <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 ® <br /> I--) J I f [a 1-st 4-ILiL Containers DP -PLASTIC DRUM <br /> B -BAG <br /> 1 Description of Waste k uantity units No TYPE BA -6 MIL PLASTIC BAG <br /> ti or WRAP <br /> t T TRUCK <br /> 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 property 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 /> Afttctions I certify and warrant that the waste has been treated in accordant with the requirements of 40 CFR Part 268 and is no longer M3-CUBIC METERS <br /> ardous waste as defined by 40 CFA Part 281 f r i Y3 -CUBIC YARDS <br /> t O -OTHER <br /> t <br /> L 1' <br /> r � <br /> Generator Authonzed Agent Name Sigriature , 5 Shipment Date <br /> [.complete eg <br /> Section II TRANSPORTER(Generator complete ad. TTranrensportersporfer <br /> TRANSPORTER [ TRANSPORTERII <br /> I <br /> a Name h Name <br /> b Address I Address <br /> c Driver Name/Title PRINT/TYPE 1 Driver Name/Title PRINT/TYPE <br /> d Phone No a Truck No k Phone No I Truck No <br /> _ Y <br /> f Vehicle License No/State m Vehicle License No (State <br /> Acknowledgement of Receipt of Materials Acknowledgement of Receipt of Materials <br /> I <br /> I <br /> 9 - n <br /> Driver Signature Shipment Date Driver Sgnature Shipment Date <br /> Section III DESTINATION (Generstor completes ad.desthtiabuiri site wmpiates epi) � <br /> a Site Name c Phone No <br /> b Physical Address d Mailing Address <br /> eepancy Indication Space <br /> I ereby certify that the above named material has been accepted and to the best of my knowledge the foregoing Is true and accurate <br /> f <br /> Name 01 Authonzed Agent Signature Receipt Date <br /> Sedbrt 9 -`=`� 's �'" "`,„�� _aASSMOS ��arm ti wee c. 77 -7 <br /> a erator's' Name _ _ b Operator's" Phone Nei <br />