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NON-HAZARD�,JS SPECIAL WASTE & k...dBESTOS MANIFEST <br /> If waste is asbestos waste, complete Sections I, II, III and IV. No. 779936 <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: i ?• b. Generating Location: i. <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 CODEDM-METAL DRUM <br /> ` Containers DP -PLASTIC DRUM <br /> ; I r y -. ' <br /> Y <br /> B -BAG <br /> j. Description of Waste: kU ntity units No. TYPE BA -6 MIL. PLASTIC BAG <br /> or WRAP <br /> r T -TRUCK <br /> 'i 1 ; 1 ' (: i �f 2 O OTHER <br /> GENERATOR'S CERTIFICATION:I hereby ceriify 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 accordan6e 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. e 3 Y3 -CUBIC YARDS <br /> O -OTHER <br /> Generator Authorized Agent Name Signature i i Shipment Date <br /> Section II e g <br /> TRANSPORTER{Generator complete a d, TranspTransporter iortei itcomplete <br /> complete t,n <br /> TRANSPORTER I TRANSPORTER II <br /> a. Name: "r,` •` h. Name: <br /> b. Address:/: I. Address: <br /> j ` t <br /> Driver Name/Title: ' ' j. Driver Name/Title: <br /> PRINT/TYPE PRINT/TYPE 1 <br /> J. Phone No.: "f f - i - �- '% e. Truck No.:i ' l`= k. Phone No.: I. Truck No.: <br /> I <br /> f. Vehicle License No./State: `� f' 'j - yam' m.Vehicle License No./State: <br /> Acknowledgement of Receipt of Materials. Acknowledgement of Receipt of Materials. j <br /> 9- 71yell <br /> n. <br /> Driver Signature Shipment Date Driver Signature Shipment Date i <br /> Section III DESTINATION (Generator completes a-d,destination site completes e4.) <br /> a. Site Name: c. Phone No.: I <br /> �. Physical Address: d. Mailing Address: <br /> i <br /> 3. <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 /> Name of Authorized Agent Signature Receipt Date ' <br /> Section IV ASBESTOS (Generator complete a-d,f,g,Operator` completes e) <br /> I <br /> a. Operator's"' Name: b. Operator's` Phone No.: <br /> Operator's" Address: <br /> i. 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, j <br /> tacked, marked,and labeled,and are in all respects in proper condition for transport by highway according to applicable international and government regulations. <br />