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,,W�.vN-HAZARDOUS SPECIAL WASTE & ASBESTOS MAMPFEST <br /> If waste is asbestos waste,complete Sections 1 II III and IV <br /> If waste is NQT asbestos waste,complete only Sections I fI and III No. 041905 <br /> GENERATOR (Generator completes all of Section 1) <br /> a Generator Name b Generating Location _i_ r� t ; '`i �) 7 <br /> c Address <br /> d Address <br /> e Phone No <br /> f 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 /> i BFi WASTE CODE TYPE <br /> t Containers DM-METAL DRUM <br /> DP -PLASTIC DRUM <br /> 1 Description of Waste r r l B -BAG <br /> k Quanfi Units No TYPE BA -6 MIL PLASTIC BAG <br /> or WRAP <br /> `< m 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 UNITS <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,0 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 acpdrdance with the requirements of 40 CFR Part 268 and is no longer a <br /> hazardous waste as defined by 40 CFR Part 261 ,-- M' -CUBIC METERS <br /> jr ! Y3 -CUBIC YARDS <br /> O -OTHER <br /> Generator Authorized Agent Name Signature Shipment Date <br /> Section IITransporter I complete <br /> TRANSPe g y <br /> ORTER Generator le a-d Tra rter II lete h-a ti' <br /> TRANSPORTER t <br /> TRANSPORTER II <br /> h Name <br /> b Address v\Lr t Address <br /> c Driver Namefritle �� - i t; r :/ . I Driver Name/Title <br /> PRINT/TYPE Ce <br /> d Phone Nd, ` J+ =— �� - �/�� a Truck NoPRINTItYPE <br /> k Phone No <br /> I Truck No <br /> f Vehicle License No/State r ._ > wh -/ C i,_ m Vehicle License NoJState <br /> Acknowledgement of Receipt of Materials Acknowledgement of Receipt of Materials <br /> g � � i �� � ✓ f `� � <br /> Driver Signature - n <br /> Shi ment Date Diner Signature S m <br /> Section III DESTINATION (Generator completeseet Oafe a-d,destination site completes a-f] <br /> 3 Site Name s f <br /> c Phone No <br /> Physical Address `s �' r- ,,r <br /> �'�' �, d Mailing Address <br /> 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 /> i <br /> Fume of Authorized Agent Signature Receipt Date <br /> Section IV ASBESTOS (Generator complete a-d,f,g,Operator'completes e) <br /> i O i's'Name b Operator's`Phone No <br /> Operator's'Address <br /> Special Handling Instructions and additional information <br /> 1PERATOR'S CERTIFICATION I hereby declare that the contents of this consignment are fully and accurately described above by proper shipping name and are classified <br /> acked,maIked,and labeled,and are in all respects in proper condition for transport by highway according to appficable intamational and government regulations <br /> Operator's`Nam,-9 Tifj, <br />