Atch 2 Sample Manifest.pdf

NON-HAZARDOUS

SPECIAL WASTE & ASBESTOS MANIFEST

If waste is asbestos waste, all sections must be completed, otherwise only Sections I, II, III need completed.

Section I GENERATOR

Section II TRANSPORTER

Section III DESTINATION

Section IV ASBESTOS

Generator Name:

Address:

Phone No.:

Description of Waste Waste Code Quantity (lbs., tons, or % of load)

1.

2.

3.

4.

5.

6.

7.

8.

Shipped in:

Rolloff Drums Truck Other

GENERATORS CERTIFICATION: I hereby certify that the above named material is not hazardous waste as defined by 40 CFR Part 261 or any applicable state law, has been properly described, classified and packaged, and is in proper condition for transportation according to applicable regulations; AND, if the waste is a treatment residue of a previously restricted hazardous waste subject to the Land Disposal Restriction, I certify and warrant that the waste has been treated in accordance with the requirements of 40 CFR Part 268 and is no longer a hazardous waste as defined by 40 CFR Part 261.

Generator Authorized Agent Name Signature Shipment Date

TRANSPORTER I

Name:

Address

Driver Name

Phone No.

Truck No. Trailer No.

Vehicle License No./State

Driver Signature (Acknowledge Receipt of Materials) Date

TRANSPORTER II

Name:

Address

Driver Name

Phone No.

Truck No. Trailer No.

Vehicle License No./State

Driver Signature (Acknowledge Receipt of Materials) Date

Generator Location:

Address:

Phone No.: County

Total Truck

Net Weight

In Tons

Site Information: Cumberland County Landfill (EPA ID: 100945) 620 Newville Road, Newburg, PA 17240

Phone: (717) 267-9550 Fax:

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

Indicate any Discrepancies:

Signature or Initials Date

Removal Contractor’s Name: Removal Contractor’s Phone Number

Removal Contractor’s* Address

Special Handling Instructions and additional information:

removal contractor’s certification: I hereby declare that the contents of this consignment are fully and accurately described above by proper shipping name and are classified, packaged, marked, and labeled, and are in all respects in proper condition for transport by highway according to applicable international and government regulations.

Name and Address of Responsible Agency:

Removal Contractor’s Name and Title (Print/Type) Removal Contractor’s Signature Date

Friable Non-friable Both: %Friable %Non-Friable

White–Original Blue–Disposal Office Copy Green–Return to Operator Canary–Generator Retain Pink–Return to Generator Gold–Transporter Retain

D

Letterkenny Army Depot 1 Overcash Avenue Chambersburg, PA 17201

Plant Trash Oil Contaminated Waste Filter Aids and Desiccant Treated Wood-Weathered Chaff Aluminized Glass Water Jet Sludge

Advanced Disposal Services Solid Waste of PA, Inc.

1192 McClellandtown Rd., McClellandtown, PA 15458

724-437-7336

105500

1308963

1308976 1308958

1308959 1308973

1308960 1