R2001-139 ACCEPTING BID AND AUTHORIZING CONTRACT

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INSTRUCTIONS FOR WASTE SHIPMENT RECORD ' I WASTE GENERATOR SECTION(Item 1-9) �_ '� 1.A Enter the name of the generatodowner faciliry at which asbestos waste is generated and the address where - the faciliy is located. Also eMe�the name of the generator/owner's contact name for the facility and the comact ` �, name's phone number. , 1.B Enter the name, mailing address and telephone rwmbe�of the ge�eratodowner oi the facility at which the � I, asbestos waste is generated. 2. If a demolit'an w renovation, eMer the name,address and telephone numbe�of the c�mpany responsible for perfortning the asbestos removal. 3. Enter the name and mailing address,and physicat site location of the waste disposal site(WDS)that will be �, �eoeiving the asbestos materials. In the appropriate spaces, also enter the phone�mber of the WDS. 4. Provide the name and address oi the Local, State,or EPA Regional office responsible for administering the i asbestos NESHAP program. (IEPA imprirned). If asbestos is hauled into an Illinois landiill br disposal from another State, scxatch out IEPA and use the proper name and�ldress of the responsible agency. 5. Indicate the types of asbestos waste materials generated. If from a dertalition or renovation, indicate the amount of asbestos that is: .Friable asbestos material •Nonfriable asbestos mate�ial- Scratch out imprinted iMormation for Friable and on 2nd line insert non�gulated�ranfriabb asbestos waste. 6. Erner the number of containers used to transport the asbestos materials listed in item 5. Also enter one of the following cornainer codes used in transporting each type of asbestos materials(specif�r any othe�type of oon- tainer used if not listed below): •DM - Metal drums, barrels •DP- Plastic drums, baRels .BA- 12 mil plastic bags or wrapping 7. Enter the quantities of each type of asbestos material removed in units of(cubic yanis). 8. Please indicate here if Bill of Lading applies and use this space to indicate special transportation,ueatmeM, storage or disposal or Bill of Lading information. If an attemate waste disposal site is designated, note it here. Emerge�cy response telephone rwmbers or similar infortnation may be inck�ded here. 9. The waste generator or authorized ageM(in writing)must read and then sign and date this certi6cation. The date is the date of receipt by transporter. NOTE: The waste generator must retain a copy of this fom�. TRANSPORTATION SECTION (Item 10 and 11) 10& 11 EMer name, address,and telephone number of each transpoRer used applicable. Print or type the full name and title of each person accepting responsibility and ack�owledginy receipt of materials as listed on this waste shipmern record for transport. EMer date of receipt and signature. NOTE: The transporter must retain a copy of this form. DISPOSAL SITE SECTION (Item 12 and 13) 12. The authorized represeMative of the WDS must note in this space any discrepancy between waste descnbed on this manifest and waste actually received as well as any imprope�ly enclosed or contained waste. Any rejected materials should be listed and destination of those materials provided. A site that oonveRs asbestos-containing waste material to nonasbestos material is considered a WDS. 13. The signature(by hand)oi the authorized WDS ageM indicates acceptance and agreement with statements on this manifest except as noted in item 12. The date is the date of the signature and receipt of shipment. NOTE: The WDS must retain a completed copy of this form. The WDS must also send a oompleted copy to the operator listed in item 2.