Document daZ7BQGbqXN7jEqvo86RoKpXR

TO BE COMPLETED BY WASTE GENERATOR STATE OF ILLINOIS ENVIRONMENTAL PROTECTION AGENCY DIVISION OF LAND POLLUTION CONTROL 0338527 2200 CHURCHILL ROAD, SPRINGFIELD, ILLINOIS 62706 (217)782-6760 Victor Products division Dana corporatxon____________ SPECIAL WASTE HAULING MANIFEST 5755 W, Roosevelt Road 8 115 3 5 Authorization Number ILCO KOSi-HAZARDOCS A5 (Company Name) Address Illinois 60650 _0 .jLi.JLJLJlJL_2JI._2.JL l4 Generator Number 34 City State Zip .'Hr. Frank, Inc. Hauler Name 201 . ll5tHASSS5ilUR(S) ______ Sow th, TloIIand , , 111--. Hauler Address 60473 , S.W.H. Registration Number .9,, _9. _Z- X.!------------- 35 31 ILDO 68506160 Hauler Name _____________________________________________ Hauler Address S.W.H. Registration Number 33 38 Land and Lakes (Facility Name) Chicago DESTINATION - DISPOSAL STORAGE OR TREATMENT SITE 2000 122n4 St. Illinois Address 60633 _o j__i_ JLJLJLJt J 33 Site Number 44 TO BE COMPLETED BY WASTE GENERATOR . City State" WASTE NAME: Asbestos Waste Zip WASTE PHASE: Solid (Liquid, Gaseous, Solid) THE SPECIAL WASTE BEING TRANSPORTED UNDER THIS MANIFEST IS OF THE DOT HAZARD CLASSIFICATION INDICATED IMMEDIATELY BELOW: SHIPPING DESCRIPTION: HAZARD CLASS: k X Boxes Lon-Hazardous WEIGHT FOR O.O.T. USE -'v 1 ^ S (circle on^ WEIGHT FOR I.E.PA USE MUST BE CONVERTED TO CU. YDS. OR GAL QUANTITY OF WASTE DELIVERED:___________________________ GALLONS (Circle One) CU. YDS 53 ' . METHOD OF SHIPMENT (Circle One) DRUMS TANK TRUCK OPEN TRUCK . OTHER (Specify). THIS IS TO CERTIFY THAT THE ABOVE-NAMED SPECIAL WASTE IS PROPERLY CLASSIFIED, DESCRIBED, PACKAGED, MARKED, AND. LABELED AND IS IN PROPER CONDITION FOR TRANSPORTATION, IN ACCORDANCE WITH THE APPLICABLE REGULATIONS OF THE DEPARTMENT OF TRANSPORTATION.. I HEREBY AGREE TO AND-CERTIFY THE ABOVE WRITTEN INFORMATION P.CU 36133 nATF- / ,/ /- ,..... 1____ ___________ _______________ :__ _1_Z Pel. 1130 .-j(Authorized Signature)_________________________________________________________________________________________________________ WASTE HAULER I HEREBY CERTIFY THAT THE ABOVE-DESCRIBED SPECIAL WASTE AND QUANTITY HAS BEEN ACCEPTED IN PROPER CONDITION FOR TRANSPORT AND I ACKNOWLEDGE THE DESTINATION AS' INDICATED: (D(Authorized Signature) DATE:______ / ___ :_J __ i_ 54 51 (2)(Authorized Signature) DISPOSAL, STORAGE, OR TREATMENT FACILITY* ------------------------------------------------------------------ HAZARDOUS WASTE SUBJECT TO FEE YES. NO. I HEREBY CERTIFY THAT THE ABOVE-DESCRIBED SPECIAL WASTE AND INDICATED QUANTITY HAS BEE-N ACCEPTED AT THE SITE SPECIFIED ABOVE: DATE:___ J_______ /_______ (Authorized Signature) ' ~~ _ _ _ _ _ _ _ _ _______________________ 60______________ _______ ** rOMMFNT^ OR ^PFOIAl INSTPlirTinNC- f y IN ILLINOIS: 217 / 782-3637 DISTRIBUTION: PART - 1 GENERATOR '24 HOUR EMERGENCY AND SPIL1, ASSISTANCE NUMBERS- PART 2 IEPA PART-3 SITE PART-4 HAULER PART 5 IEPA OUTSIDE ILLINOIS: 800 / 424-8802 PART-S GENERATOR GENERATOR COPY - PART 6 VPD- 189-00019U DANA-002