Laserfiche WebLink
l NON-HAZARDOUS SPEOFAL WASTE & ASBESTOS MANIFEST <br /> i <br /> Ifwaste is asbestos waste,complete Sections I,11 11I and IV N O. 005974 0 5 9 7 4 <br /> /l <br /> If waste is NOT asbestos waste complete only Sections 1,11 and III 1�l 11 <br /> loll I GENERATOR (Generator completes all of Section]) <br /> a Generator Name f uti iCU'` SCT fes``"E}iv Cni;lf.0X 1 —4,_75 <br /> b Generating Location <br /> c Address d Address LSU, LLI jf_'I;, nUji, l K0 <br /> rOL E A <br /> e Phone No f Phone No <br /> If owner of the generating facility differs from the generator provide <br /> g Owners Name h Owners Phone No <br /> TYPE <br /> I BFI WASTE CODE h t 1 L} f 7 Containers DM-METAL DRUM <br /> DP -PLASTIC DRUM <br /> B BAG <br /> I Description of Waste k uantity Units No TYPE BA 6 MIL PLASTIC BAi <br /> m m or T TRUCK <br /> WRAP <br /> O OTHER <br /> GENERATORS CERTIFICATION 1 hereby certify that the above named materiat is not a hazardous waste as defined by 40 CFR Part 261 or UNITS <br /> any applicable state taw 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 p accordance with the requirements of 40 CFA Part 268 and is no longer a M' CUBIC METERS <br /> hazardous waste as defined by 40 CFR Part 261 � Y' CUBIC YARDS <br /> O -OTHER <br /> Generator Authorized Agent Name Signatures Shipment Date <br /> Section II TRANSPORTER Generator oom rete a-d Transporter 1 complete%g <br /> P Trans her 11 cam late h-n } <br /> TRANSPORTERI TRANSPORTERII <br /> awe A-1,14AST'E T".'-,S nil fATION h Name <br /> b Address e`4 i5 I.LAGIe S AVENUE t Address <br /> SAE MARTIN, Ct <br /> c Driver Name/Title t` r'7 - r` ) Driver Name/Titje-/' <br /> PRINTrrYPE I-,' PRINT/TYPE <br /> d Phone No a Truck No k Phone No i Truck No <br /> I Vehicle License No/State /t - m Vehicle License No/State <br /> Acknowledgement of Receipt of Matenals Acknowledgement of Receipt of Materials <br /> /J 1Ti <br /> g `,� - '�! 'G1- 14n <br /> Driver nature lipmen!Date Dnver Signature Shipment Date <br /> SectiA III DESTINATION (Generator completes a-d destination site completes e-f <br /> a Site Name I VASC } c Phone No <br /> b Physical Address d Mailing Address <br /> "Off- ` _ -. C-C, <br /> e Discrepancy Indication Space <br /> 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 ` <br /> Name of Authorized Agent Signature Receipt Date <br /> S,Wton IV ASBESTOS (Generator complete a-d,f,g,Operator'completes a) <br /> a erator's'Name b Operator's'Phone No <br /> c Operator's"Address <br /> d Special Handling instructions and additional information <br /> OPERATORS CERTIFICATION I hereby declare that the contents of this consignment are fully and accurately described above by proper shipping name and are classif <br /> packed,marked and labeled,and are in all respects In proper condition for transport by highway according to applicable international and government regulations <br />