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NON-HAZARDOUS SPECIAL WASTE & ASBESTOS MANIFEST <br /> If waste is asbestos waste,complete Sections 1 II III and IV �� I (t't(1 (7 C <br /> If waste is NOT asbestos waste complete only Sections I Il and III NV 0 U T p <br /> Section I GENERATOR (Generator completes all of Section 1) <br /> a Generator Name CI z\'Kt' �rii b Generating Location <br /> CT�� r,J 9—4 2 7 5 ' <br /> c Address d Address 2'J5 vLf\�rL rxs� rrUl.�, GhUb� S1 Y1✓F'1 Y. _,L%t <br /> I,TOCKTOIN, C-'1 <br /> e Phone No I Phone No <br /> If owner of the generating facility differs from the generator provide <br /> g Owner's Name h Owners Phone No <br /> TYPE <br /> BFI WASTE CODE FUM3 , Containers DM-METAL DRUM <br /> DP -PLASTIC DRUM <br /> B BAG <br /> I Description of Waste k Quantity Units No TYPE BA 6 MIL PLASTIC BA( <br /> or FF11m m T TRUCK O -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 slate law has been properly described classified and packaged and is in proper condition for transportation according to P POLINDS <br /> applicable regulations AND,It the waste is a treatment residue of a previously restricted hazardous waste subject to the Land Disposal Y YARDS <br /> Restrictions 1 certify and warrant that the waste has been treated irraccordance withe reifCnrements of 40 CFR Part 268 and is no longer a M' CUBIC METERS <br /> hazardous waste as defined by 40 CFR Part 261 / ;� Y' <br /> CUBIC YARDS <br /> A <br /> ` r O -OTHER <br /> j. C <br /> Generator Authorized Agent Name Signa urs `/ Shipment Date <br /> Transporter I complete e� <br /> Section H TRANSPORTER (Generator complete ate, Trans rte,,I1 cam lets h-n <br /> 49 TRANSPORTER l TRANSPORTER II <br /> a Name ALLUASTE TRANSPORTATION h Name <br /> b Address 12475 LLAGAS AVENUE I Address <br /> SAN HART A,i, CA ! � <br /> c Driver Name/Title r� �Y �y�' ' � I Driver Namerritle ` <br /> ` w f f�� PRiNTIrYPE 1 PRINTfrYPE <br /> d Phone No e TruckN k Phone No I Truck No <br /> 17 <br /> f Vehicle License NOJState ��� l7 C m Vehicle Llcense P40 istate <br /> Ac0owledgem nt of Receipt of Materials Acknowledgement of Receipt of Matenals <br /> ci��;f/I'L ��i 12 6 <br /> g n <br /> Driver ate nature Shipment Data Driver S nature ShEavrit Date <br /> Section III DESTINATION (Generator completes a-d destination site completes ea) <br /> a Site Name '�f' 1 VAS(,u ';J. c Phone No <br /> b Physical Address 4001 s���� P­hL d Mailing Address <br /> e Discrepancy Indication Space <br /> I hereby certify that the above named matenal has been accepted and to the best of my knowledge the foregoing is true and accurate <br /> I Name of Authorized Agent signature Reoeipt Dafe <br /> 10f1 N ASBESTOS (Generator comptete a-d,f,y,Operator•WmPletes e) <br /> a Operator's'Name b Operators*Phone No <br /> c Operator's*Address <br /> d Special Handling Instructions and additional information <br /> OPERATOR'S CERTIFICATION t hereby declare that the contents of this consignment are fully and accurately described above by proper shipping name and are clas <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 />