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Waste No 1067845 <br /> Systems TM 3 INDUSTRIES NON-HAZARDOUS SPECIAL WASTE MANIFEST <br /> INDUSTRIES <br /> IteratorName "-± Generating Location <br /> rens `- ` ' Address <br /> ne No Phone No <br /> m Containers Type <br /> 3FI Waste Code <br /> Description of Waste Quanta Units No T pe D Drum <br /> ElL---ter t C Carton <br /> B - Bag <br /> T _ Truck <br /> ❑ m ❑ P - Pounds <br /> ' Y - Yards <br /> ❑ m ❑ O- Other <br /> I hereby certify that the above named material does not contain free liquid as defined by 40 CFR Part 260 10 or any applicable <br /> state law, is not a hazardous waste as defined by 40 CFR Part 261 or any applicable state law, has been properly described, <br /> classified and packaged, and is in proper condition for transportation according to applicable regulations <br /> 1 <br /> 3e tar Authorized Agent Name Signature Shipment Date <br /> TRANSPORTER <br /> T k No Phone No - <br /> Transporter Name Driver Name (Print) <br /> kiress Vehicle License No/State <br /> Vehicle Certification <br /> I <br /> eby certify that the above named material was picked up I hereby certify that the above named material was delivered with- <br /> e generator site listed above out incident to the destination listed below <br /> T= <br /> r Signature Shipment Date Driver Signature Delivery Date <br /> DESTINATION <br /> Site Name L �f .�1 y y - - -~ Phone No <br /> jress <br /> reby certify that the above named material has been accepted and to the best of my knowledge the foregoing is true and accurate <br /> I I I = <br /> V o1 Authorized A eni Signature Recei t Date <br /> i <br /> PASS CODE <br /> ' _ 13F1260 720 3r93 <br />