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m <br /> # r NON-HAZARDOUS SPECIAL WASTE & ASBESTOS MANIFEST <br /> ' <br /> if Waste is asbestos waste,complete Sections I II 111 and Iv NO. 041901 li 1 9 n 1 <br /> I If 4vaste is N T asbestos waste,complete only Sections 1,11 and III f�1 L!'-F.L u <br /> Section i ` GENERATOR (GenomtorcomMetesatlofsectwn3) <br /> a Generator Name b Generating Location <br /> c Address f <br /> r` !. d Address <br /> e Phone No f Phone No <br /> It owner of the generating facility differs from the generator,provide <br /> g Owners Name h Owners Phone No <br /> TYPE <br /> d I J d <br /> Fc <br /> T-MM Containers DM-METAL DRUM <br /> i BFI WASTE CODE L i r 7 / r I 1 l' DP -PLASTIC DRU, <br /> 8 -BAG <br /> I Description of Waste r rr� I/ k Quantic units No TYPE BA -fi MIL WRAP <br /> m mT TRUCK <br /> O -OTHER <br /> GENERATOR S CERTIFICATION I hereby certify that the above named matenal is not a hazardous waste as defined by 40 CFR Part 261 or <br /> UNITS <br /> any applicable state taw has been property described classified and packaged and is in proper condition for transportation according to P -POUNDS <br /> applicable regulations AND,it 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 METEF <br /> s' _CUBIC UBIC NERD` <br /> hazardous waste as defined by 40 CFR Part 261 O -OTHER <br /> Generator Authorized Agent Name Signature Shipment Date <br /> x Transporter I complete <br /> Section II TRANSPORTER Generator [eta a-d, Trans rter u complete h-n Z114 ` <br /> TRANSPORTERI TRANSPORTERII <br /> a Name }-. <br /> r; 1 f e , i j hName <br /> b Address �nn�� f 4 1- �` � 'C f -4 i Address <br /> � <br /> C 1'i r <br /> c Driver Name/Titie ! f����� I Driver Name/Title <br /> Pfl[NTlTYPE PRINT/TYPE <br /> d Phone No a Truck No ' k Phone No I Truck No <br /> f Vehicle License No/State r� V `f m Vehicle License No/State <br /> Acknowledgement of Receipt of Materials Acknowledgement of Receipt of Matenals <br /> r n Shipment—[ <br /> g Sh nt Date Driver S nature <br /> Driver 64gnature <br /> Section III DESTINATION (Generator completes a-d,dostination site completes e4) <br /> a Site Name c Phone No <br /> b Physical Address d Mailing Address <br /> e Discrepancy Indication Space <br /> I hereby certify that the above named matenal has been accepted and to the best of rrly Rowledge the foregoing is true and accurate <br /> .T rfj r <br /> f ` { dr l Receipt tate <br /> Name of Authorized Agent Signature � <br /> Section TV AtBESTOS (Generator plate ate,f,g,operator•oompietes e) <br /> b Operators' Phone No <br /> a Operator's`Name <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 i able international ve by proper <br /> shipping <br /> �nt regulations d ar <br /> packed marked and labeled and are in all respects in proper condition for transport by highway accordingto app_ <br /> 1�` <br />