SITE INFORMATION AND CORRESPONDENCE

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NON-HAZARDQ)S SPECIAL WASTE & "BESTOS MANIFEST If waste is asbestos waste, complete Sections I, II, I1I and IV. NO, 779914 If waste is NOT asbestos waste, complete only Sections I, II and III. Section I. GENERATOR (Generator completes all of Section t) r 3. Generator Name: k ` b. Generating Location: _ I ;. Address: d. Address: •_;; � Phone No.: / f. Phone No.: f owner of the generating facility differs from the generator, provide: 1. Owner's Name: h. Owner's Phone No.: TYPE BFI WASTE CODE DM-METAL DRUM :/ - Containers DP -PLASTIC DRUM B -BAG Description of Waste: k. u ntity units No. TYPE BA -6 MIL. PLASTIC BAG or WRAP i fr It JI T TRUCK r'4 x I iL�l TO OTHER t tj� •1 f' ir!'�f � �f� F f GENERATOR'S CERTIFICATION:I hereby certify that the above named material is not a hazardous waste as defined by 40 CFR Part 261 UNITS i or any applicable state law,has been properly described,classified and packaged,and is in proper condition for transportation according to P -POUNDS applicable regulations;AND,if the waste is a treatment residue of a previously restricted hazardous waste subject to the Land Disposal Y -YARDS Restrictions,I certify and warrant that the waste has been treateddn accordanceAvith the requirements of 40 CFR Part 268 and is no longer M3-CUBIC METERS a hazardous waste as defined by 40 CFR Part 261. ,- Y3 -CUBIC YARDS } J O -OTHER Generator Authorized A66fit Name Signature { /% ., Shipment Date Transporter I complete e-g Jection II TRANSPORTER(Generator complete a-d: Transporter it complete trn TRANSPORTERI TRANSPORTERII it. Name: h. Name: >. Address: i. Address: i :. Driver Name/Title: j. Driver Name/Title: PRINT/TYPE PRINT/TYPE 1. Phone No.: e. Truck No.: k. Phone No.: 1. Truck No.: i Vehicle License No./State: m.Vehicle License No./State: Acknowledgement of Receipt of Materials. Acknowledgement of Receipt of Materials. 3• n• Driver Signature Shipment Date Driver Signature Shipment Date Section III DESTINATION (Generator completes a-d,destination site completes a4.) i. Site Name: c. Phone No.: �. Physical Address: d. Mailing Address: f. Discrepancy Indication Space: I hereby certify that the above named material has been accepted and to the best of my knowledge the foregoing is true and accurate. Name of Authorized Agent Signature Receipt Date Section IV ASBESTOS (Generator complete a-d,f,g,Operator" completes e.) t. Operator's" Name: b. Operator's` Phone No.: :. Operator's` Address: 1. Special Handling Instructions and additional information: )PERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by proper shipping name and are classified, -acked,marked,and labeled, and are in all respects in proper condition for transport by highway according to applicable international and government regulations.