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NON-HAZARDOUS SPECIAL WASTE & ASBESTOS MANIFEST <br /> GM <br /> I <br /> If waste Is asbestos waste,complete Sections 1 11 III and IVAllbk O. 005962 O () rG] <br /> 1f waste is NOT asbestos waste complete only Sections[ 11 and [II J <br /> On I GENERATOR (Generator completes all of Section t) <br /> Y <br /> a Generator Name �1' �Vr(, A:: --WON b Generating Location <br /> c Address d Address - - _ <br /> L I('1(,i,Tr � <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 BEI WASTE CODE ( 1 1 j ry : () C j Containers DM-METAL DRUM <br /> DP -PLASTIC DRUM <br /> B BAG <br /> I Description of Waste k Ou ntity Units No TYPE BA 6 MIL PLASTIC B/ <br /> or U] mm T TRUCK[1O OTHER WRAP <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 law has been property 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 rsstncted hazardous waste subject to the Land Disposal Y -YARDS <br /> Restrictions I certify and warrant that the waste has been treateyf�in accordance h theirements of 40 CFR Part 268 and is no longer a M' CUBIC METERS <br /> hazardous waste as defined by 40 CFR Part 261 ,-'/fr Y3 -CUBIC YARDS <br /> /I ��O/1�c /� / ` ` _ b O -OTHER <br /> Generator Authorized Agent Name Sc ature Shipment Date <br /> Section II TRANSPORTER Generator coin lete a-d Transporte <br /> p Transport <br /> rans iter 11 coinr t complete e g <br /> fete h-n <br /> TRANSPORTER I TRANSf ORTER II <br /> lame ALLWASI F _Z :al 0TAI 101' h Name <br /> b Address )e4 7 5 LLACAS yVEI~ 'OE I Address / <br /> r <br /> SAP- IvAk1:-}3 CA f <br /> c Driver Name/Tdle Driver Name/Title <br /> c � V /�� J PRINTIrYPE [,� / PRINTfrYPE <br /> d Phone No rl 7 ! e Truck No �r k Phone No _ I Truck No <br /> f Vehicle License NoJState m Vehicle License'No/State <br /> Acknowledgerpent of Receipt of Matie'rials Acknowledgement of Receipt of Materials <br /> Driver SigrkaW4 Shipment Date Driver signature Shipment Date <br /> Section III DESTINATION (Generator completes a-d destination site completes e-f) <br /> a Site Name NF1 fkSCU rt l- c Phone No <br /> b Physical Address Z N,VT&Y� C (-IZi, d Mailing Address <br /> e Discrepancy ndication 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 i ! <br /> Name of Auihonzed Agent Signature ' Receipt Date <br /> Ion N ASBESTOS (Generator complete a-d,f,g,Operator"completes e) <br /> a eratoes*Name b Operator's*Phone No <br /> c Operators'Address <br /> d Special Handling Instructions and additional information <br /> OPERATOR'S CERTIFICATION i hereby declare that the consents 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 />