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If wast8 is asbestos waste complete Sections 1 11 I11 and IV �h plow 10 ,f1 �_9[:7 r <br /> I If waste is NOT asbestos waste,complete only Sections 1 Il and[II ��i �� <br /> r <br /> Sqqbonj I; GENERATOR (Generator completes an of Sectton 1) <br /> a erator Name ` r' ` u '.7" <br /> _ b Generating Location <br /> 'l <br /> c Address d Address <br /> e Phone No I Phone No <br /> If owner of the generating facility differs from the generator provide <br /> g Owners Name In Owners Phone No <br /> TYPE <br /> i BFI WASTE CODE m ` Containers DM-METAL DRUM <br /> DP -[BLASTIC DRUM <br /> B -BAG <br /> I Description of waste k Quantit Units No TYPE BA -6 MIL PLASTIC BA( <br /> or_U FF1WRAP <br /> a m O -OTHER <br /> GENERATOR S CERI IFICATION 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 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 Y3 -CUBIC YARDS <br /> O -OTHER <br /> Generator Authanzed Agent Name Signature Shipment Date <br /> Transporter f complete e g <br /> Section II TRANSPORTER Generator complete a-d Trans iter 11=plate t3 <br /> TRANSPORTERI TRANSPORTERII <br /> Y � <br /> a Name i � - In Name <br /> beress ' �` r Address <br /> c DriverNameTtle ! .Y s ^r 'ter!` �� � l ik ) DriverNamelTdle <br /> PRINTMIDE PRINTPYPE <br /> d Phone No a Truck No - k Phone No I Truck No <br /> f Vehicle License No/State ' m Vehicle License No/State <br /> Acknowledgement of Receipt of Materials Acknowledgement of Receipt of Matenals <br /> g - J'dn <br /> Diner Signature Shipment Date t Driver Signature Shipment Date <br /> Section III DESTINATION (Generator completes a-d destination site completes a-f) <br /> a Site Name s r c Phone No <br /> _ f <br /> b Physical Address d Mailing Address <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 /> f Name of Authonzed Agent Signature Receipt Date <br /> Section IV ASBESTOS (Generator complete a-d,f g,Operator"completes e) <br /> a <br /> clirator s*Name b Operator's*Phone No <br /> rator'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 classif <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 /> e Operators*Name&Title <br /> PrinvType operator s Signature Date <br />