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I <br /> IJON-HAZARDOUS SPECIAL WASTE & ASBESTOS MANIFEST <br /> t <br /> r <br /> if w4ste is asbestos waste,complete Sections 1 II III and IV No. 005965% <br /> I if waste is NOT asbestos waste,complete only Sections 1 II and III <br /> �.. GENERATOR (Generator completes all of Section 1) <br /> lr`iL.�j� )N �.��� V-' t CLLURO ` 9 LA 75 <br /> a Generator Name b Generating Location <br /> c Address d Address ' �tN 1'G' <br /> 1{ JC To P. <br /> e Phone No f Phone No <br /> If owner of the generating facility differs from the generator,provide <br /> �R' r <br /> g Owner's Name h Owner's Phone No <br /> TYPE <br /> I BFI WASTE CODE mr] 5 j 1 U {, Mk -, r Containers DM-METAL DRUM <br /> DP PLASTIC DRUM <br /> B BAG <br /> I Description of Waste k Qu ntity Units No TYPE BA -6 MIL PLASTIC BA <br /> or <br /> m T TRUCK <br /> O OTHER WRAP <br /> GENERATOR S CERTIFICATION I hereby cerbly 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 /> Restrictions I certify and warrant that the waste has been treated in accordance with the requirements of 40 CFR Part 268 and is no longer a M' -CUBIC METERS <br /> hazardous waste as defined by 40 CFR Part 261 Y' -CUBIC YARDS <br /> O -OTHER <br /> Generator Authorized Agent Name Signature Shipment Date <br /> Transporter 1 complete e g <br /> Section II TRANSPORTER (Generator complete a-d Tran iter 11 corn jets h-n <br /> TRANSPORTERI TRANSPORTER1 <br /> a me ALLWA-I'1i TI.�+�� ,"Jr;�h`t 101N h Name <br /> b Address y I Address <br /> i <br /> S yJ� : '3'IN P <br /> c Driver Name/Title r ---y;.l'rJ._e I Driver Name/Title <br /> PRINTrFYPE f i PRINTA-YPE <br /> d Phone No �J `� C, e Truck No - f k Phone No I Truck No <br /> I Vehicle License Na/State m Vehicle License No/State <br /> Ack9o)vledgement of f ecelpt 6f Materials f Acknowledgement of Receipt of Materials <br /> g ver nature <br /> Stlipment Date Driver Signature Shipment Date <br /> Section IIT DESTINATION (Generator completes a-d,destination site oomp4etes e-f) <br /> a Site Name 1S1 i VA` (0 n1 <br /> c Phone No <br /> b Physical Address d Mailing Address <br /> ,_j <br /> e Discrepancy indication Space <br /> I hereby certify that the above named material has been accepted and to the belt of my knowledge the foregoing Is true and accurate <br /> f Name of Authorized Agent Signature Receipt Date <br /> on Iv ASBESTOS (Generator complex a-d f,g,operator completes e) <br /> a Aerators'Name �`r 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 classi <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 />