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NON-HAZARDOUS SEAL WASTE & ASBESTOS MANIFEST <br /> I if waste is asbestos waste complete Sections 1,II,111 and IV o 005967 O 6]C <br /> If waste is NOT asbestos waste,complete only Sections 1 II and III NM <br /> Ction I i GENERATOR (Generator completes all of Section I) <br /> a Generator Name i.rt1 v A0'N' -SPIN _:.«ii A b Generating Location <br /> c Address d Address L0,115 i�� -y' I I\, h©Li Cjt0"3 bird_ET P"7, 0 <br /> STOChTO' _ <br /> e Phone No I Phone No <br /> If owner of the generating facilily differs from the generator provide <br /> g Owners Name h Owner s Phone No <br /> TYPE <br /> I 8F1 WASTE CODEm ;J y r Containers DM-METAL DRUM <br /> ILLL���LL��LLLJJJJ DP -PLASTIC DRUM <br /> B BAG <br /> I Description of Waste k Ouanti Unils No TYPE BA -6 MIL PLASTIC B, <br /> or WRAP <br /> 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 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 treed accordance-i ldh the requirements of 40 CFR Part 268 and is no longer a !1113 CUBIC METERS <br /> hazardous waste as defined by 40 CFR Part 261 Ya CUBIC YARDS <br /> /I O -OTHER <br /> Generator Authorized Agent Name Signature i Shipment Date <br /> Section 11 TRANSPORTER {Generator complets ate, Transporter I complete e� <br /> Trans iter ti coin tete h-n <br /> TRANSPORTERI TRANSPORTERII <br /> 10ame r„,LWASTE TPL&,�SPOk.TAT L r' h Name <br /> b Address 1�415 LLAGAS zi'F.�L i Address <br /> S3µ4 rL"TIF, CA <br /> c Driver Name/Tttle n o' _!'7 r /�t �t t Driver Name/- itle <br /> PRIW/TYPE PRINT/TYPE <br /> d Phone No'/ `�`� Tr-�� -' e Truck Nok Phone No / I Truck No <br /> / l <br /> I Vehicle License No/State r# ' .5 ' ! m Vehicle License NoJState <br /> Acknowledgement of Recent of Materials Acknowledgement of Receipt of Materials <br /> g 1A I k I DLI n --- <br /> Diner Si nature .. <br /> ShiEnent Date i Driver Si nature Shipment Date <br /> Section III DESTINATION (Generator completes a-d,destination site completes e-f) <br /> a Site Name n F'k- VA"CC c Phone No <br /> b Physical Address 41✓r�t �3k SGL' d Mailing Address <br /> ,Vr�'.,,t�,., <br /> e Discrepancy Indication Space <br /> I hereby certify that the above named material has been accepted and to the best of my knowledge the foregoing is true and accurate <br /> r <br /> f Name 01 Authonzed Agent Signature Receipt Date <br /> tion IV ASBESTOS (Generator complete a-d,t,g,operator'completes e) <br /> a Operator's'Name b Operator's`Phone No <br /> c Operator's'Address <br /> d Special Handling Instructions and additional Information <br /> OPERATOR'S CERTIFICATION l hereby declare that the contents of this consignment are fully and accurately described above by proper shipping name and are cia^ <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 />