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i <br /> ® <br /> I <br /> NON-HAZARD6-4S SPECIAL WASTE & )vdBESTOS MANIFEST <br /> If waste is asbestos waste, complete Sections I, II, III and IV. No- 779935 <br /> If waste is NOT asbestos waste, complete only Sections I, II and III. <br /> ;ection L GENERATOR (Generator completes all of Section I) <br /> Generator Name: f'`. \l t <br /> b. Generating Location: ,.1 <br /> Address ' 1 d. Address: V. ` <br /> Li <br /> Phone No.: `'i-. f. Phone No.: <br /> 'owner of the generating facility differs from the generator, provide: <br /> Owner's Name: h. Owner's Phone No.: <br /> TYPE <br /> BFI WASTE CODE Containers DM-METAL DRUM <br /> DP -PLASTIC DRUM <br /> B -BAG <br /> Quantit Units No. TYPE BA -6 MIL. PLASTIC BAG <br /> Description of Waste: k. or WRAP <br /> I� T -TRUCK <br /> f •< i E "N ,? ! } •! 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 i <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 beenitreated in accordanob 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 /> Generator Authorized Agent Name Signature r �1 <br /> Yf� Shipment Date. .j:_ i <br /> Transporter I complete e-g <br /> )'ection II TRANSPORTER(Generator complete a-d; Transporter 11 complete h-n) , <br /> TRANSPORTER [ TRANSPORTERII <br /> I <br /> Name: h. Name: <br /> Address: i. Address: <br /> i <br /> Driver Name/Title: j. Driver Name/Title: <br /> PRINT/TYPE PRINT/TYPE <br /> Phone No.: e. Truck No.: k. Phone No.: I. Truck No.: <br /> Vehicle License No./State: m.Vehicle License No./State: <br /> Acknowledgement of Receipt of Materials. Acknowledgement of Receipt of Materials. <br /> i <br /> n. <br /> Driver Signature Shipment Date Driver Signature Shipment Date <br /> )ection III DESTINATION (Generator completes a-d,destination site completes e-f_) <br /> Site Name: c. Phone No.: i <br /> I <br /> Physical Address: d. Mailing Address: <br /> i <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 /> i <br /> 1 <br /> Name of Authorized Agent Signature Receipt Date <br /> i <br /> t <br /> )ection IV ASBESTOS (Generator complete a-d,f,g,Operator* completes e.) <br /> Operator's* Name: b. Operator's* Phone No.: <br /> Operator's* Address: <br /> Special Handling Instructions and additional information: <br /> -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, <br /> acked, marked,and labeled,and are in all respects in proper condition for transport by highway according to applicable international and government regulations. 1 <br />