HomeMy WebLinkAbout1997-11-26 Hazardous Waste Disposal Verification HFI No: 2655106
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1 140012 HAW A E O. 37 7 4 N I tti.1!1* 25. Ow
STI ASBESTOS S 3. al In PP 250M 77
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I hereby certify that this load does not contain any unauthorized
hazardous w4*.
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SIGNATURE: ONLY THROUGH BR/UARCO CONTRACT
260-1 16LF (3)
•••■••■••• ■••■•• •■■•••• ..■• a■•• •■••••W ■IPPER 'MC
RH No: 2G 55107
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Ticket # : An79 CMS # : ZOR329 LHS 4; OW0999 Nre Bend laPlf11:.
HOST COMMUNITY ASREE 0.37
WASTE ASSESSMENT FEE 0.67
ABATEMENT FEE 1.
STATE TAX 1.67
Total
Check Tende roc 43
Change Due— $ .ae
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Thank: & Have A Great Gay !
I hereby certify that this load does not contain ariji unauthorized
hazardous waste._
SIGNATURE
znorico rm.!, v ruoru tnu OCIA I A onn rv A , .
HFI NON- HAZARDE.4S SPECIAL WASTE &
If waste is asbestos waste, complete Sections I, II, III and IV. w , O ■ 19 4 7 4 7
If waste is NOT asbestos waste, complete only Sections I, II and III. , �I
t t2 I . . °. .°>-..E RAT i r ter all of A
'aw- Generator Name: , kc IN. .,k 1, \,„ i t k,t" b. Generating Location: t" e 3 ,. ..'^- --'
c. Address .. 4rsi -' l A. , e ' :, ....., d. Address: "j t j %) ) �. I ,.,...,..\,,, /t.)
e. Phone No.: Z7' 1 Oett5 t' t f. Phone No.: X ?`"'(
If owner of the generating facility differs from the generator, provide:
g. Owner's Name: h. Owner's Phone No.:
r TYPE
1. BFI WASTE CODE '',7 /, / Th Containers DM - METAL DRUM
DP - PLASTIC DRUM
Description of Waste: . ' °,, `,_ B -BAG
j. p ' t k. Quanti U nits No. TYPE BA - 6 MIL. PLASTIC BAG
or i K WRAP
�, = T TRUCK
O - OTHER
GENERATOR'S CERTIFICATION: I hereby certify that the above named material is not a hazardous waste as- defined by.50 Part 261 or UNITS
any applicable state law, has been properly described, classified and packaged, and is in proper conditiorrfor fransportation jccording to P - POUNDS
applicable regulations; AND, if the waste is a treatment residue of a previously restricted waste subject to the Land Disposal Y - YARDS
Restrictions, I certify and warrant that the waste has been treated in accordance with the repair rttents of 40 CFR Part 268 and is no longer a M - CUBIC METERS
ha;ardcz \ waste as defined by 40 CFR art 261. I Y 3 - CUBIC YARDS
'L {�'� � ,I 0 - OTHER
d g }
4 7 i r
Generator Au Agent Name 'N - "Signatute—" . Shipment Date
i g
411,01. 1 ANS O' ER` Oentitator, complete at " Tree er II ete h ,
TRANSPORTED I f TRANSPORTER II
a. Name: k r "( ,L,:)
.,1. 141, 1 I 5P h. Name:
b. Address: '` 'i.. `;" ? i,_)/ , ^r-}z, t I -„, .:._ i. Address:
c. Driver Name/Title: r `#° ,- .i =' '1t5 ' •' :.... Driver Name/Title:
.i; PRINT/TYPE PRINT/TYPE
d. Phone No.: '' :4 ci e. Truck No.: k. Phone No.: I. Truck No.:
f. Vehicle License No. /State: m. Vehicle License No. /State:
Acknowledgement of Receipt of Materials. Acknowledgement of Receipt of Materials.
t
I r n.
Driver Si. nature _ , Shi.ment Date Driver Si. nature Shi.ment Date
�. ESTI AT/ON ( 3neralor.CtIMPlet u 't estinatttn OW
a. Site Name: I c. Phone No.:
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b. Physical Address: d. Mailing Address
OM:T. $,
e. 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.
. t •. /
I
Name of Authorized Agent Stgn4e " .., Receipt Date "
a. Operator's'. Name: b. Operator's* Phone No.:
c. Operator's* Address:
d. Special Handling Instructions and additional information:
OPERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by proper shiping name and are classified,
packed, marked, and labeled, and are in all respects in proper condition for transport by highway according to applicable intemattanal and governrp`ent regulations.
e. Operator's' Name & Title , ..: , `' tii'i #5 �G°+,r ., = .1 }.' -y I', 1 '
Print/Type , _-, perator's Signature Date
f. Name and Address
of Responsible Agency:
g. ❑ Friable; ❑ Non- friable; ❑ Both % friable % nonfriable
* Operator refers to the company which owns, leases, operates, controls, or supervises the facility being demolished or renovated, or the demolition or renovation operation, or both.
REORDER ONLY THROUGH BFI / UARCO CONTRACT GENERATOR RETAIN 0 260