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NON-HAZARDOUS SPECIAL WAS&E & ASBESTOS MANIFEST <br /> ' 9 If waste Is asbestos waste,complete Sections 1 it,III and!V No. 041.96 <br /> If waste is NOT asbestos waste,complete only Sections 1 11 and III <br />;eC I GENERATOR (Generator completes all of Section 1) _ <br /> Generator Name b Generating Location <br /> d Address J <br /> Address <br /> I Phone No _ <br /> Phone No <br /> f owner of the generating facility differs from the generator provide <br /> I Owner's Name h Owner s Phone No <br /> TYPE <br /> H `` u� C J c i Containers DM- <br /> M-METAL DRUM <br /> BFI WASTE CODE `- ,f �� i ) t - DP -PLASTIC DRUM <br /> B BAG <br /> k Mal <br /> Units No TYPE BA -6 MIL PLASTIC BAG <br /> Description of Waste or WRAP <br /> T -TRUCK <br /> 0_-OTHER <br /> [I <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 <br /> UNIT <br /> any applicable state law has been properly described classified and packaged and is m 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 y�ilh the requirements of 40 CFR Part 268 and is no longer a M3 _CUBIC METERS <br /> hazardous waste as defined by 40 CFR Part 261 i ' } r ,�1�i� _ , O OTHER <br /> Shipment Date <br /> Generator Authorized Agent Name <br /> Signature <br /> Transporter 1 complete e-g <br /> Section II TRANSPORTER Generatorcomplete a-d, Tran ern fete h n <br /> TRANSPORTERII <br /> TRANSPORTERi <br /> ve <br /> h Name <br /> a <br /> Address <br /> b Add ress <br /> ) !'�I / ' � ��j1 <br /> c Driver Name/Title ' `t ``' Driver Name/Title PRtNTmPE <br /> r `f _ r PRINTfryPE I Truck No <br /> d Phone No _ <br /> e Truck No k Phone No <br /> m Vehicle License No/State <br /> f Vehicle License No/State -° <br /> AAcknowledgement of Receipt of Materials <br /> Acknowledgement of Receipt of Materials <br /> ( '�I f_ �, f n Shi inent Date <br /> g f/ shipment Date Driver Si nature <br /> Drner St nature <br /> Section III DESTINATION (Generator completes a-d destination sate oompleles e-t <br /> Phone No <br /> a Site Name <br /> Mailing Address <br /> b Physical Address _ <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 Receipt Date <br /> Name of Authorized Agent OfSignature <br /> ion IV <br /> ASBESTOS (Generator complete a-d,f.g Operator'completes a) <br /> b Operators'Phone No <br /> a Operator`s'Name <br /> c Operator's"Address <br /> d Special Handling Instructions and additional information <br /> d above <br /> y proper <br /> OPERATOR'S CERTIFICATION are m all decece'l at the contents proper condition ffthisor consignment <br /> port by highway arefully and accurately desc ng to applicablenntemat onaband governmentgregu regulations are clas <br /> packed marked and labeled,andf--T— <br />