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v <br /> EDNON-HAZARD'S SPECIAL WASTE & _313ESTOS MANIFEST <br /> If waste is asbestos waste, complete Sections I, II, III and IV. No. 779912 <br /> If waste is NOT asbestos waste, complete only Sections I, II and III. <br /> Section I. GENERATOR (Generator completes all of Section I) <br /> a. Generator Name: �j '•� f "' b. Generating Location: f <br /> c. Address: ' d. Address: <br /> e. Phone No.: 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 /> TYPE <br /> i. BFI WASTECODEf } s � ryf Containers DM-METAL DRUM <br /> DP -PLASTIC DRUM <br /> B -BAG <br /> j. Description of Waste: } k. Qu ntity Units No. TYPE BA -6 MIL. PLASTIC BAG <br /> or WRAP <br /> f j t t 1 f F TTRUCK <br /> `.fr i � I � .:. % •.)l ���c l�} �! 'r f� t.. i t � � � O -OTHER <br /> GENERATOR'S CERTIFICATION:I hereby'certify that the above named material is not a hazardous waste as de ned by 40 CFR Part 261 UNITS <br /> or 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 M3-CUBIC METERS <br /> a hazardous waste as defined by 40 CFR Part 261. i j Y3 -CUBIC YARDS i <br /> O -OTHER <br /> Generator Authorized Agent Name r Signature i Shipment Date <br /> Transporter t complete e-g <br /> Section II TRANSPORTER(Generator complete a-d; TransporterrtI complete h-n) <br /> TRANSPORTERI TRANSPORTERII ; <br /> 3. Name: - �' h. Name: <br /> �. Address: `f f <br /> i. Address: <br /> Driver Name/Title: r` •''k, A" !~'- j. Driver Name/Title: <br /> PRINT/TYPE PRINT/TYPE i <br /> J. Phone No.: e. Truck No.: k. Phone No.: I. Truck No.: j <br /> Vehicle License No./State: �'f�� `Lf'_% m.Vehicle License No./State: <br /> Acknowledgement of Receipt of Materials. Acknowledgement of Receipt of Materials. <br /> w (`i r n. <br /> Driver Signature Shipment Date Driver Signature Shipment Date <br /> Section III DESTINATION (Generator completes a-d,destination site completes e-f.) <br /> t. Site Name: c. Phone No.: <br /> f. Physical Address: d. Mailing Address: <br /> Discrepancy Indication Space: <br /> i <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 /> Name of Authorized Agent Signature Receipt Date <br /> lection IV ASBESTOS (Generator complete a-d,f,g,Operator* completes e.) <br /> I. Operator's* Name: b. Operator's* Phone No.: <br /> Operator's* Address: <br /> t <br /> 1. Special Handling Instructions and additional information: <br /> )PERATOR'S CERTIFICATION: 1 hereby declare that the contents of this consignment are fully and accurately described above by proper shipping name and are classified, <br /> acked,marked,and labeled,and are in all respects in proper condition for transport by highway according to applicable international and government regulations. <br /> M.— R. Ti1in- <br />