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NON-HAZARD,,,JS SPECIAL WASTE & ,.,SBESTOS MANIFEST <br /> If waste is asbestos waste, complete Sections I, II, I1I and IV. NO. 779913 <br /> If waste is NOT asbestos waste, complete only Sections I, II and III. <br /> Section I. GENERATOR (Generator completes all of Section t) <br /> a. Generator Name: b. Generating Location: <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 WASTE CODE t ` DM-METAL DRUM <br /> t i r i ;f Containers DP -PLASTIC DRUM <br /> t. B -BAG <br /> j. Description of Waste: k. u ntity Units No. TYPE BA -6 MIL. PLASTIC BAG <br /> or WRAP <br /> tf• ) T -TRUCK <br /> #'t , <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 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. Y3 -CUBIC YARDS <br /> O OTHER <br /> J. t /` t '- <br /> Generator Authorized Agent Name Signature _ a j Shipment Date <br /> Section II TRANSPORTER(Generator complete a d; 7iattsportBi Il corrnplate M, <br /> TRANSPORTERI TRANSPORTERII <br /> a. Name: h. Name: <br /> b. Address: i. Address: <br /> c. Driver Name/Title: j. Driver Name/Title: <br /> PRINT/TYPE PRINT/TYPE <br /> d. Phone No.: e. Truck No.: k. Phone No.: I. Truck No.: <br /> f. Vehicle License No./State: m.Vehicle License No./State: <br /> Acknowledgement of Receipt of Materials. Acknowledgement of Receipt of Materials. <br /> g. n. <br /> Driver Signature Shipment Date Driver Signature Shipment Date <br /> Section III DESTINATION (Generator completes a-d,destination 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 material has been accepted and to the best of my knowledge the foregoing is true and accurate. <br /> f. <br /> Name of Authorized Agent Signature Receipt Date <br /> Section IV ASBESTOS (Generator complete a-d,f,g,Operator" completes e.) <br /> a. Operator's'` Name: b. Operator's' Phone No.: <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 described above by proper shipping name and are classified, <br /> packed,marked,and labeled,and are in all respects in proper condition for transport by highway according to applicable international and government regulations. <br />