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NON-HAZARDOUS SPECML WASTE 4 ASBESTOS MANIFEST <br /> Wa No. : <br /> V 6 <br /> If waste is asbestos waste complete Sections 1 11 III and IV No. i (� <br /> If waste is NOT asbestos waste complete only Sections 1,11 and ill 1 M <br /> anon I GENERATOR (Generator completes all of Section 1) <br /> a Generator Name (1h-'fir 1( 1 '­'!, IJU IC A b Generating Location _ CHEVRO.; 9-4275 <br /> c Address d Address --905 HOLI C;):n°S ST.tf I-T !'­7' <br /> _; LOC,t ION, CA <br /> e Phone No f Phone No <br /> if owner of the generating facility differs from the generator,provide <br /> g Owner's Name In Owners Phone No <br /> TYPE <br /> i BFI WASTE CODE L t 0 Ju I i % I Containers DM-METAL DRUM <br /> DP -PLASTIC DRUM <br /> B -BAG <br /> I Description of Waste k Ou ritity Units No TYPE BA -6 MIL PLASTIC Bi <br /> or WRAP <br /> m m T -TRUCK <br /> O -OTHER <br /> GENERATORS CERTIFICATION 1 hereby certify that the above named material is not a hazardous waste as defined by 40 CFR Part 261 or UNITS <br /> 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,if the waste is a treatment residue of a previously restricted hazardous waste subject to the Land Disposal Y YARDS <br /> Restnctions I certify and warrant that the waste has been treated id-accordance with Pe requirements of 40 CFR Part 268 and is no longer a M3 CUBIC METERS <br /> hazardous waste as defined by 40 CFR Part 261 <br /> J Y3 -CUBIC YARDS <br /> O -OTHER <br /> Generator Authorized Agent Name Signature Shipment Date <br /> Section II TRANSPORTER Generator complete a-d, TTassportterr LIcoominplteetteehi <br /> TRANSPORTERI TRANSPORTERII <br /> Wme ALLW.ASTL TRS NSPOR!,-,TION h Name <br /> b Address 12475 LLAGAS A�TFN E <br /> i Address <br /> i <br /> SAN MARTIN, CA C,�/ <br /> c Driver Name/Title _L E- 1✓e�,F2 _, j Driver Name/Title <br /> T/ <br /> ! t PRINrYPE / "7 PRiNMYPE <br /> d Phone No Q7 e Truck No k Phone No 'f I Truck No <br /> I Vehicle License NoJState �. D m Vehicle License NoJState <br /> Acknowledgement of Receipt of aterials Acknowledgement of Receipt of Materials <br /> Driver Signature Shy meet Date Driver Signature Shipment Bate <br /> Section III DESTINATION (Generator completes a-d,,destlnation site completes e-f) <br /> a Site Name c Phone No <br /> b Physical Address `11f'}}tryG1 L a�' �'`'�'C`� i�C 1� d Mailing Address <br /> 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 f y` <br /> Name of Authorized Agent Signature Receipt Date <br /> Section IV ASBESTOS (Generator comptete aA f,g,Operator'completes e) <br /> rator s"Name b Operator's"Phone No <br /> c Operator's'Address <br /> d Special Handling instructions and additional information <br /> OPERATOR'S CERTIFICATION I hereby declare that the contents of this consignment are fully and accurately described above by proper shipping name and are class) <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 /> r, r'lnnra Mr'c` rU'omn A Til.. _ <br />