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i NON-HAZARDOUS STIEOIAL WASTE & ASPESTOS MANIFEST <br /> r <br /> If waste is asbestos waste,complete Sections 1 11 Ili and IVAOL #' <br /> If waste is NOT asbestos waste,complete only Sections 1 11 and lit ,V o. t005971-3 <br /> Ion 1 GENERATOR (Generator completes all of Section I) <br /> a Generator Name j=x l ' _ '1J\ b Generating Location ( =t+ tti'�i —«?-7 i <br /> c Address d Address '9 'ik-L" n%"A : Los" <br /> e Phone No f Phone No <br /> If owner of the generating facility differs from the generator provide <br /> g Owners Name h Owner's Phone No <br /> TYPE <br /> i BFI WASTE CODE tl Containers DM-METAL DRUM <br /> DP -PLASTIC DRUM <br /> B -BAG <br /> 1 Description of Waste k Ou ntity Units No TYPE BA -6 MIL PLASTIC F <br /> or WRAP <br /> 1 t 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 CFA 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 acoordaric"ith 140 requirements of 40 CFR Part 268 and is no longer a Mn CUBIC METERS <br /> hazardous waste as defined by 40 CFR Part 261 -CUBIC YARDS <br /> O OTHER <br /> Generator Authorized Agent Name SignatLre r Shipment Date <br /> r <br /> Transporter1 complete e g <br /> Section II TRA SPORTER (Generator complete a-d Transporter <br /> 11 oom lefe h-n <br /> TRANSPORTER] TRANSPORTERII <br /> h Name <br /> b Address 4,5 I,LA,�AS -'V Arl"I, i Address <br /> SAT\ i 1A'I 1°:,, V/ <br /> c Driver NamelTrtle _ 4': .-y t_ . s4 4, ) Driver Name/Title v <br /> �- _ -- PRINTlrYPE PRtNTrrYPE <br /> d Phone No �` f i i -7"`�/Vic.' a Truck No �� = k Phone No I Truck No <br /> rr <br /> I Vehicle License No/State ) �� f tE m Vehicle License No/State <br /> Acknowledgement of Receipt of Materials Acknowledgement of Receipt of Materials <br /> I ITTg r�--� •��J n <br /> Driver Si nature <br /> shipment Dale I Dmrer Signature Shipment Date <br /> Section III DESTINATION (Generator completes a-d destination site completes a-f) <br /> a Site Name t r> > C Phone No <br /> b Physical Address J�1" d Mailing Address <br /> � 1v.r_ <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 /> f / <br /> Name of Authorized Agent Signature Receipt Date <br /> Alliftction XV ASBESTOS (Generator complete a-d f g,Operator"completes e) <br /> a Operator's"Name b Operator's' Phone No <br /> c Operator's"Address <br /> of Special Handling Instructions and additional information <br /> OPERATOR'S CERTIFICATION 1 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 appllcableinternat+onal and government regulations <br />