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<br /> �� ONYX NORTH AMERICA CORP. ...:�5 / C% � � I
<br /> �ONYX WSR# � �.n ,�i.. .. ;�,
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<br /> WASTE SHIPMENT RECORD/ASBESTOS MANIFEST 24 Hour Response Telephone Number i
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<br /> Special Waste Profile# ��
<br /> 1. Work Site Name and Mailing Ad�ess� � � ,_,, �, ,�0 Owner's Name Owner's Phone No. I
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<br /> � I 2. Operator's Name and Address Operator's Phone No. ;
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<br /> ' ' 3. Waste Disposal Site(WDS) Name, Mailing Address, and Physical Site WDS Phone No. '
<br /> Onyx Valley View Landfill 217-963-2976
<br /> 1363 Bear Rd., Decatur, IL 62522 �
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<br /> � i 4. Name and Address of Responsible Agency . . , - , �
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<br /> � 5. Description of Materials ,,6�eontainers 7.Total Quantity
<br /> I � HAZARDOUS SUBSTANCE, SOLID N.O.S. ` No. Type m' (yd')
<br /> i � (ASBESTOS) RQ ORM-E NA 9188 - �
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<br /> 8. Special Handling Instructions and Additional Information I
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<br /> y i 9. GENEFiAT.OR CERTIFICATION:I hereby declare that the contents of this consignment are fully and accurately described
<br /> ' above by proper shipping name and are classified, packaged, marked and labeled/placarded, and are in all respects in proper �II
<br /> condition for transport according to the applicable international and national governmental regulations.I hereby certify that I
<br /> , the above named material is not a hazardous waste as defined by 40 CFR Part 261 or any applicable state law, has be�` �
<br /> � � probably described, classified and packaged, and is in proper condition for transportation according to applicable regulaiions, i
<br /> ; AND,if the waste is a treatment residue of a pr�.viously restricted hazardous waste subject to the Land Disposal ,
<br /> � � Restrictions, I certity and warrant that the waste has been treated in accordance with the requirements of 40 CFR Part 268 �
<br /> ; � and is no longer a hazardous waste as defined by 40 CFR Part 261.
<br /> � P�nted/Typed Name&Title r _ � �� i ,, ,.,� r,,: �ig� ture ; � r Month _, Day ..- Year ' �
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<br /> i ', 10. Transporter 1 (Acknowledgement of Receipt of Materials) '
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<br /> � � Printed/Typed Name&Title Signature Month Day Year �
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<br /> � Address and Telephone No. � • ' 'r�' "t`��' �`' '(" � � �
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<br /> � 11. Transporter 2 (Acknowledgement of Receipt of Materials)
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<br /> ~ ! PnntedlTyped Name&Title '.Signature Month Day Year �,
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<br /> Address and Telephone No. ��I
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<br /> �I 12. Discrepancy Indication Space
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<br /> � � 13. Waste Disposal Site Owner or Operator: Onyx Valley View Landfill, 1363 Bear Rd., Decatur, IL 62522
<br /> o ' Certification of receipt of asbestos materials covered by this manifest except as noted in item 12.
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<br /> WHITE -Waste Disposal Site CANARY -GeneratodOperator PINK -Transporter GOLD - GeneratodOperator
<br /> DCE-01 1-91
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