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OZM <br /> '^ F41160 >RUN-nA"KD0U4 SPECIAL WASTE & ASBESTOS MANIFEST <br /> 621887 If waste is asbestos waste,complete Sections I, II, III and IV <br /> If waste is NOT asbestos waste,complete Sections I,II and III <br /> I• <br /> GENERATORGenerator completes la-r) <br /> e.Generator's US PA ID Number b.Men <br /> fest acyrrent Num or c. Page 1 of f <br /> d. GeOerators Name and Location: e. eneretor's McAing Address: <br /> tI 1 <br /> Phone: Phone: k t.? r <br /> If owner of the generating facility diffars from the generator,proWda: <br /> h. Owner's Name: <br /> I. Owner's Phone No.: <br /> I.Waste Profile# k. Exp. Date 1.Waste Shipping Name and m <br /> Deacd don n.Total o. Unit <br /> _ No. e n WWaI <br /> i <br /> Mil 2016 <br /> 0 TOR' C ICA ON: 1 hereby Certify that the above named material is not a haze ous waste as defined by 40 C R 281 or any applicable <br /> state low,has been properly described,clessMed and packaged,and la In proper condition for transportation according to applicable 2 regulations;AND, a this <br /> waste h a treatment residue of a pr9/ouaiy restricted hazardous waste subject to the Land Disposal Restrictions.I certify and warrant that the Waste has <br /> been treated In 8000Menciss with requirements of 40 CFR 288 and Is no longer a hazardous waste as defined by 40 CFR 291. <br /> .Oensrator Authorluci ant Name PrlM <br /> T .81 nature r.Date <br /> 11. for I II <br /> e. ransporter'e Name and Address: <br /> b Phone: <br /> G Driver Name Print d.SI nature a. Date <br /> Ill. DESTINATION (Generator complete Illa-c and Destination Sks completes Illd-g) <br /> a.Disposal Facility and SPe Address: c.US EPA Number d. Discrepancy Indication Space: <br /> b. <br /> I her c$rttfv that th vs nem material has been ecce ted an-toth,beat of m owl a fo oln Ia true d e urate. <br /> s.Name of-Authorized Aj eM Pdnt f.Signature ate <br /> N. ASBESTOS (Generator completes IVa-f and Operator complete IVg-i) <br /> a. psrstor's Name and Address: c.Responsible Agency Name and Address: <br /> P <br /> e. pedal Handling Instructions and Additional Information. d.Phone: <br /> F •Fri 1 oth <br /> Friable •F <br /> OPERATO 'S CERTI (CATION: I hereby dedere that the contents of this consignment ars pY and accurately described above by the proper shipping name <br /> and ars dasalAad,packaged,marked and faboled/piacerded,and are in all respects M proper condition for transport according to applicable Intematlonal and <br /> national governmental uladona. <br /> I n to I. to <br /> :Qmgin s aompar y ch owna, sesee, rates,controls,or supe ase s slog tlemolls sd or renovated,or the demclltlon or <br /> ronovatlltn operation or both <br /> :Ev 12f10 GENERATOR RETAIN <br /> RS-F11A <br />