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f NON-HAZARDOUS S SGIAL WASTE & ASBESTOS MANIFEST <br /> If <br /> If waste is asbestos waste complete Sections 1,11,111 and IV NO. 1005968 0 0 CJ 9 6 U <br /> Q <br /> ° If waste is NOTasbestos waste,complete only Sections I,It and III 1�1 <br /> Wctlon I GENERATOR (Generator completes all of Section 1) <br /> a Generator Name C` �' ` 4'� hA1.1U: C T"VR -N 9-'4-'75 <br /> b Generating Location <br /> c Address d Address z9, -' 1'I I`�'f` 111 1,0i�r, LROSS SIKLL, ?I ..rtt <br /> 57 <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 m , _ y U 3 Containers OM-METAL DRUM <br /> DP PLASTIC DRUM <br /> B -BAG <br /> I Description of Waste k Qu nlity Units No TYPE BA -6 MIL PLASTIC B <br /> or WRAP <br /> m m O -OTHER <br /> GENERATOR S CERTIFICATION I hereby certify that the above named matenal 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 p previously restricted hazardous waste subject to the Land Disposal Y -YARDS <br /> Restrictions I certify and warrant that the waste has been treated En accordance with the requirements of 40 CFR Part 268 and is no longer a M' -CUBIC METERS <br /> hazardous wpste as defined by 40 CFR Part 261 / / 4"", <br /> l, X Y' -CUBIC YARDS <br /> F7 It- I , O -OTHER <br /> Generator Authorized Agent Name Signature Shipment Date <br /> Section II TRA SPORTER (Generator complete a-d iTM.=,ter ii Com{stele hen <br /> TRANSPORTER I TRANSPORTER II <br /> lame ZUWASTE !,ANS20O� TA I IOR h Mame <br /> b Address J- 415 LI GAS AVENUE t Address <br /> SA'N MARTIN, CA <br /> c Driver Namel7Ette e / I Driver Name/Title <br /> PRINTIfYPE PRENT/TYPE <br /> d Phone No a Truck No k Phone No I Truck No <br /> f Vehicle License NoJState m Vehicle License No/State <br /> Acknowledgement of Receipt of Materials Acknowledgement of Receipt of Materials <br /> n EE <br /> DriverSignature Shipment Date I Dover Signature Shipment Date <br /> Section III DESTINATION (Generator completes a-d destination site completes a-f) <br /> a Site Name -�I' VntiLC '- c Phone No <br /> b Physical Address " i � Ct 3 t.UE� ' d Mailing Address <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 /> Name of Authorized Agent Signature ' Receipt Date <br /> .Siaction IV ASBESTOS (Generator complete a-d f,g,Operator'completes e) <br /> a <br /> Aerators`Name b Operators`Phone No <br /> c Operators'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 clan <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 />