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i NON-HAZARD 0S SPDIAL WASTE & ASBESTOS MANIFEST <br /> if waste is asbestos waste,comolele Sections 1,11 til and IV <br /> If waste is NOT asbestos waste,lcomplete only Sections 1,11 and m "��• 003 ,159 <br /> , <br /> •n I GENERATOR (Generator completes all of section q r <br /> G' t p!l/ U s b Generating LocationYy S U P AI rq M'fly �G�� t✓ <br /> a &enerator Name 1 <br /> c Address ? /?o r ✓e ti/ 4 " A/D,T �f d Address <br /> e Phone No t Phone No <br /> If owner of the generating facility differs from the generator provide <br /> g Owner's Name h Owner s Phone No <br /> TYPE <br /> M-METAL DRUM <br /> i BFI WASTE CODE D ' 1 -aS C� FT= <br /> Containers QP -PLASTIC DRUM <br /> $ -BAG <br /> 1 Description of Waste L k Quandt units No TYPE BA -6 MIL oPLAS IC BAC <br /> a m T r WRAP <br /> 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 CFR Part 261 or <br /> UNITS <br /> any applicable state law has been property 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 M3 _CUBIC METERS <br /> ATER <br /> hazardous waste as defined by 40 CFR Part 261 O -OTHER <br /> F= <br /> Generator Authorized Agent Name Signature Shipment Date <br /> Transporter I complete 11 <br /> Section II TRANSPOR'T'ER (Gerierator complete a-d, Tcansporterticorn Tete h-n <br /> TRANSPORTER I TRANSPORTER U <br /> tome I�•%cU r�S,oPr� r blid -f �'�r>~e in i h Name <br /> b Address =Z ' 449 4 S Q i Address <br /> Sh1 ldlvf%J1� `� ��n y� <br /> c Enver NamelTitle >57r ! n Illy �7Ci I Driver Name/Title <br /> PRINT/o G PRINTl7YPE <br /> d Phone No <br /> e Truck No f D y k Phone No I Truck No <br /> f Vehicle License No/Stale y�`"` m Vehicle License No/State <br /> Acknowledgement of Receipt of Materials Acknowledgement of Receipt of Matenals <br /> n Shipment Date <br /> gDiner nature Shi merit Date Driver S lure <br /> 'Section III DESTINATION (generator completes e-d destination site completes e-1) <br /> a Site Name c Phone No <br /> b Physical Address d Matting 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 /> t � Receipe Date <br /> Name of Authorized Agent Signature <br /> Iiion IV ASBESTOS {Generator complete a-d,f,g,OpeWGIA completes a) <br /> dW <br /> I perator's'Name b Operators`Phone No <br /> c Operator's"Address <br /> d Special Handling Instructions and additional information <br /> OPERATOR'S CERTIFICATION 1 hereby declare that the contents of this consignment are fully and accurateiyible anlemaUove onaby proper shipping name and and government regulations aare clas <br /> packed marked,and labeled,and are in all respects in proper condition far transport by highway according to app <br />