05016_Southern Mfg_Waste Manifest

. -~ 1056."",.. ;jl..THIS IS NOT AN INVOICE
For 24 Emergency Response
Phone: [phone] :Oi"e:rsi1ied Fax: [phone]
P.O. Box 11030
Rock Hill, SC 29731
~eoycIin.g~I:n.c.
EPA ID # SCR000766048
Bill of Lading :,,/1 / ZVCustomer # _ Date:-""c,,-,-+' "
o New Account Truck #: _
__---L1 _o Address Change Zone#: _ P.O. #/
Generator Bill To
Customer: }'l -­! " , ( ; rl: -l ( /I
Address: .' ,­-jl . r ( , Vl I, i-J(. ( .
,­
J' "
Customer:
Address:
I /. , i i :; : -,ill' '. /' I{ /'/11_'/( {'-! ~
Contact:
Zip: Zip:
Contact:
Phone: ( ) Phone: ( )
Materials Quantity Unit Price Total
A. Used Oil Filters
B. Non-Haz Liquids
C. Non-Haz Solids
D. Hazardous Waste Liquid , ;f I /. I. r I \ ) ~ (tJ},\~
E. Hazardous Waste Solid
'i
G. Used Tires
F. Parts Washer Service
H. Fluorescent Bulbs
1. A.bsorbent Sales .' i
J \ I ,'.-, I.
. \! --1 ii.I ,r '. &. \. '.jK. ~. -
L.
M. Processing Fee
TOTAL CHARGE
.........Diversified Recycling, Inc. Agent (Sign): __..:....:_:!..:....,',.__~""';""'----'-_
, f
Generators Certification:
I certify that the materials above are accurately described, classified, packaged, marked, and labeled, and are in proper condition for transport
according to applicable state, EPA, and D,G,T. regulations, Furthe~more, I ha~e no knowledge of an hazardous waste contained or mixed with the material
that is to be transported, I, the generator, expressly agree and promise to hold Diversified Recycling, Inc, and all of its officers and employees free from and
otherwise indemnify the same against any and all penalties and other liability resulting from the transfer of any such materials that would cause it to be
unacceptable under this manifest.
iAuthorized Customer Agent (Sign):'_'-1/-"-,,-;:_.-'---'----'­,.-----,--'--,.­_
Authorized Customer Agent (Print): _.,-.._/~/__~/-'--',-"_'__/_--'-'-'__!.----'-,_~_F.'__/_i~/I _
(OF) (PW) Frequency: _

White -Facility Copy/Original Yellow -Tliplicate Pink -Customer Copy

5i7!
13.
Total
QuantityNo. Type
12. Containers
/'"t~·.c.
817-682-0234
E. Handling Codes for Wastes LLsJlld Above
A. Tran porter's Phone)Lt~) -l.f (1 )
B. Transporter's Phone
C. Facility's Phone
Manifest Doc. No.1022
US EPA 10 Number
US EPA ID Number
Signature'
Signature
SignatU\~
Signature
S.C.R.O.O.O.7.6.6.0.4 a
6. US EPA 10 Number
S. C.~. Q. C. O. 7.'6.0.0.4.8
10.
8.
GENERATOR'S COpy
3c1'. /)
"
<'", r~ .' I f >-J-/> / (~.)/..­~ . .)\... ,(.. ...1
4. Generator's Phone (? l.? )
9. Designated Facility Name and Site Address
DlVeRSlFlED ~YCt.JN6 f8C.
1.,Al..SJ'itGHT AD.
ROOK HILL. SO 28V38
D. Additional Descriptions for Materials Listed Above
5. Transporter 1 Company Name.
DtV£RSfREO RECYCLJNG U'lC.
d.
a.
11. Waste Shipping Name and Description
7. Transporter 2 Company Name
15. Special Handling Instructions and Addilionallnformatlon
F
A
C11------,­_
L 20. Facility Owner or Operator: Certification of receipt of waste materials covered by this manifest except as noted in Item 19.I
~I--------------------------,-------------------------PrintedITyped Name
3. Generator's Name and Mailing Address
16. GENERATOR'S CERTIFICATION: I certify the materials described above on Ihis manifest are not subject to federal regulations [or reporting proper disposal of Hazardous Waste.
G b.
E
N
~~--------------------------------+--+-+----+------
A c.
T o
R I--------------------------------------+-----jf--+-----+-­
T 17. Transporter 1 Acknowledgement of Receipt of Materials R . / ~ Prlntew.r..Y.e2.~.~ame ", //
S 'l (" J ". ; ,:,l·/__I
b 18. Transpo'rre; 2 Acknowledgement of'fl'8~eipt of Materials R ~ PrintedfTyped Name
R
Printedfryped Name
19. Discrepancy Indication Space
TYPE OR USE BALLPOINT PEN
PRESS FIRMLY .. ALL COPIES NC DEPARTMENT OF HEALTH AND HUMAN SERVICES
DIVISION OF PUBLIC HEALTH
HEALTH HAZARDS CONTROL UNIT MUST BE LEGIBLE
NORTH CAROLINA ASBESTOS WASTE SHIPMENT RECORD

1. Waste Generator/Owner Name and Address:
F"j' IJ... ,;0 ,ut ,'II (:J / 11.! I V'J NC v-r.~f'"o IV,. 1" . 2:
/q L/ GI ()l [J ":kJ~ i},,~'d ..: 4 fd
Work Site Name and Physical Address: N C fA l\ ~ I c-r ~( lr'" L'
I i\t-< U· <...l"() I"'? 06-1 ",/)} I (j, ,{ l.,~;t.~. >.0 ",1<'" 1 " I ~~. v ,.A
Waste Generator/Owner Phone Number:
~
2. Contractor Name and Address: E:' A ';,-r
'13 {) 5-· F~ ,A'I C (\ ,,"'"tJ 'e i"-J
I \.) r\ -r \.A)~' ~1 ( tc/\' ,­
C ,;(' .. ~I lJ-p r~L '2 ~ I ~h"
3. Wllste Disposal Site (WDS) Name, Mailing Address: ..L \~ V"j(.tJl"l ". ;;; I"') ,I i' TIP 1\ . ,'\ V I· 'i "'­" .. I --." ~-•,,/ . \ .\ F" ~ ~ .'7-u U '·,-<,f.( I ~t
fV' '1', C111-eCl<....i i L 1-"Y~ L C~I
WDS Physical Site Location: .. ~
t ...
NC Landfill Permit II: \.1 1/' . l}lj
4. Name of Responsible Agency:
[ ] Forsyth Co. Environmental Affairs Dept.
WI-Mecklenburg Co. Dept. of Environmental Protection
[ ] NC DHHS .. Health Hazards Control Unit [ JWNC Regional Air Pollution Control Agency
Permit II: NI"L·
Start Date:, _
NESHAP (ACTS) 10 11: _
Complete Date: _
5. Description of materials: /'. IL _ (.:J... c-.fi_/)/~-e ... IC»
6. Containers
Number:_....,....__ IType: ,
Vehicle: RQ, ASBESTOS, CLASS 9
NA 2212, III
7. Total Quantity (ycf)m':It LcjC1t.
8. Special Handling Instructions and Additional Information:
EMERGENCY CONTACT: DIVISION OF EMERGENCY MANAGEMENT AT 1-800-858-0368
I ,
9//f/1i 1-"Date (MMlDDIYY):
9. CONTRACTOR'S CERTIFICATION: I hereby declare that the contenta of this consignment are fUlly and accurately described above by proper shipping
name and are classified, packed, marked, and labeled, and are In all respects In proper condition for transport by highway according to applicable
International and goVer.D~nl~gulatl~ns. _; prlntedITYJ>l!_g.~)me,~Title:?')fli a-<~ l-/ (.1.l1(.; /3 ,q ()fA'.~ h
Signature: -I' /I---z1I~...Y""1 / -j
10. Transporter 1 (Acknowledgment of Receipt of Materials):
prlntedlTyped~ae & Itle: '1)b I} ':':1 W\ LS-l( r /L/l~.
/C-' ....../,\
Address: oJ . ") • ~.I'I M, 0 r? ,1.iIi t> h.' $vI ,I,,. c-
Signature: /&--?/ i4 y,...,.Jo .. __-­.l.~
I .~. ;".\ .yfi".i) J, '.
I
I 11. Transporter 2 (Acknowledgment of Receipt of Materials):
PrlntedlTyped Name & TllJe:, _
Address: Phone Number:_"_'~_" _
Signature: Date (MMlDDIYY):
12. Discrepancy Indication Space:
13. was.te DISposnSltp: A 1 )})ror ope~f.:l1rt"lcrtI07of R~elpt off'sbetstC\S Materials Covered by this Manifest, ExcePt~.8"'N'?ted.-lJI~e"l1l1~.. t 1 ..'1 i) n' f\ J ii \h j t',...., (" ,I.."W,/ "'-)' -­--:=. L bt prlntefyped Na &'IT1 Itl;~ q1" .. ' J\j ./ , 'Lk -j LUi C~.v"<f Lr /,]V Total Weight (Tons): (/), l~'~11")/\ . /! ) j',', ," )! 1;1/' /\ -t· Jj " ,") "~ J'l I '." j".Slgnat~e:_ ../ ,/ t. I JA~ V\. A._ ~ L"i r IL' \.,9 /?.~l-..-J Date (MMlDDIYY): t~J t)/ I...., jU \
DHHS 3787 (Revfsedlll99) \~ ....
Health Hazards Control Unit
(1 copy-Waste Generator/Owner; 1 copy-Contractor; 1 copy ·.Transporter; 1 copy -Disposal Site; 1 copy· Health Hazards Control Unit)
TYPE OR USE BALLPOINT PENNC DEPARTMENT OF HEALTH AND HUMAN SERVICES PRESS FIRMLY -ALL COPIES DIVISION OF PUBLIC HEALTH MUST BE LEGIBLE HEALTH HAZARDS CONTROL UNIT
NORTH CAROLINA ASBESTOS WASTE SHiPMENT RECORD
Waste Generator/Owner Phone Number: Work Site Name l!nd Physical Address: 1. Waste Generat",r/ow~r Name an,d Address: FI f.y.J..('( tv11 I .s .d-(..Ife /01 N~ V l.. S I C (::tC1t:)t~:
(I=falfI ) ~}g1L--0(0 fd-~}WOO S-'eO.... ;)Uil <.~ 54-CR ~-:;d":":wtpJq)b1/~., O£'R 7Ht~p Rf}rJ, "'3 tCC (·r I LXC) C -

r~. ',-" ..d-~/IJ .(~ CU/·.... ('
r -'j Contractor Phone Number: 2. Contractor Name and Address: z:-(.i >f' ." .--,,' (-':;'1:; L{ b"LiS'. /fo ItJc~ t __ --.. L 1.'1--­)'13u.,f t'll ( .n\,';,.....1 <: t··~o Cht/~1 I'D ~~; ;\Jc... L. ~ .-.... ~;; I
WDS Phone Number: WDS Physical Site Location: 3. Waste Disposal Site (WDS) Name, Mailing Ad ress: .'­.~.r~t .W'ro. ( -'. \(~ ,Vi~ )¥ . rrv:...f\.. "-.... (~f i I) )-(1-['7 31.0 77­.::':II:',~n\...Q :-()~) Lfl.¥IL" -iZ~' I<~(~ '"_" , ,ff.{NC Lan~1II Permit II: {~C.J ~.# .flh7, r-71)e() !v'C t . .( .-s(J{/j
4. Name 01 Responsible Agency:
[ w:.0rsyth Co. Environmental Affairs Dept. Permit II: t'llt. NESHAP (ACTS) 10 II: it'V ecklenburg Co. Dept. of Environmental Protection

[ 1NC DHHS -Health Hazards Control Unit Start Date: Complete Date:

[ 1WNC Regional Air Pollution Control Agency

5. Description of materials: a~) L3..( Colo S'
7. Total Quantity (yd')m':6. COntainers Vehicle: RQ, ASBESTOS, CLASS 9 Number: /0 Vi rzA .NA 2212, III I (lv··n..£ ilyt,A.(~....' ..Type: ~
8. Special Handling Instructions and Additional Information:
EMERGENCY CONTACT: DIVISION OF EMERGENCY MANAGEMENT AT 1-800-858-0368
9. CONTRACTOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by proper shipping
0, name and are classified, packed, marked, and labeled, and are In all respects In proper condition for transport by highway according to applicable
International and gpver, men~ regulations. , f t I .I .." , .." .J .'1 .... . .', ,'1 .PrintedlType_~Oe & Title: [ ~Vi Ja··( rt/1 I )5 {J-.... k OIL,· j I I • "'LH-ot/J/1 ~f ...,.} ~I I 31 O~Signature: -. IpYJ .__.--'.." Date (MMlDDIYY): i)J C
10. Transporter 1 (Acknowledgment of Receipt of Materials): .,.......:

I ...~ I I' / _..~

.
/11'1(;'/ r~ ~..<./</ ! I--:.:~. /1. ";/-i (../ .-PrlntedITyped Name & Title: ,
! r (;i 7('-0·' .!

Address: /-"'/ / /:..///> '':-/i:"""'L Phone Number: /i<' i.f-~.... _' // /'06"',"1

".... I '7;I !! /;;'/1/ '. ,.iv.' Y'" ,,I l-,....-:"'--{;:'".. I ,Signature: !. ,Y ....·'/M /'(l '" "-'-' Date (MMlDDIYY): . • .''" i
11. Transporter 2 (Acknowledgment of Receipt of Materials):
PrlntedlTyped Name & Title:
.~~r.t.. Address: Phone Number:
Signature: Date (MMlDDIYY):
12. Discrepancy Indication Space:
"
13. ~aste Disposal Site: I, f\O~1~~ or, Ope~at9r eettlflbatlo? of: Recel'pt ~f A~!'.!~top.Mat!i(rlaIS 'c7ered by this Manifest. Except !I~N0W()I(I Item..(12.
, 1/\ ,IV ''; n rJ" J I J f'l ,t·'! }y"'hh !J, ( n i Ij \ 7-'p-} .Prl1tedITYPf~anir&~III,:J Il, I I. \J, .J ••A "~_' 1. I.r.~j 11..,). TotaIWelght(Tons)~~ "/"/ -f f: v..)\ " it) 1/1 /"){ I{ /'. ! -t·, ~JIL Ii (1-1 J .slgnalur.eA 1/. , Iff I! l.. j i Date (MMlDDIYV): Cll. 1/ .! .I . , ,_, ,....,__.rr,)
~DHHS 3787 (~evlsed8l99)
Health Hazards Control Unit
(1 copy-Waste Generator/Owner; 1 copy-Contractor; 1 copy -.Transporter; 1 copy -Disposal Site; 1 copy -Health Hazards Control Unit)