2401 TAYLOR DR 2021-02-25 - Laserfiche WebLink

ASN 4 ASB TOS WASTE TE SE1IPMENT IIPORT FO RM e"..% . PLEASE PRINT OR TYPE!If you have questions,contact your local DEQ Regional Office in Portland at(503)229- 5364,Salem at(503)378-8240 ext.272,Medford at(541)776-6010 ext.235,or Bend at(541)388-6146 ext,226,OR call(800)452-4011 for the location of your local regional DEQ office. WASTE GENERATOR: (Contractor,Facility,or Operator) t(( �/�� E 1, Asbestos removal site name and address: oA tea I ` f -- �°'- _ � — d� 6 7 Street City/State County Zip Contact person:C.0'Dt, N E-5+\3 i Phone: C ?u'a .311 k • 2, Operator's�� name and ad ess: iAU,2 'i PA t, )/r .l Mvz;rt o J Phone: 5 3�9 -3,/.// `� Gt� h�Cr `7. )i ..;,10 Street �City tate County Zip • 3. Waste disposal site: It i liY stt'D [ti�j'L b (i int�' t 1 I Phone: say 1 - .G(fl- Lib R-.D• asp she e� th U i� 't ie (YZ-. Ct UD Street City/State County Zip 4. Describe asbestos materials: / T� . 5. Containers: Number: � Type: G7 o- c� 6. Total quantity(cubic yards): 1 ,C et c- • 7. OPERATOR'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 according to all government regulations. All movement of this asbestos-containing • material is recorded on tpis Waste Shipment Record Form. f/ Name:_ C U oL r 1.21 ompany: P(.CeLLI JG, ^1 Signature: Date: -3 / LI I 0 0 TRANSPORTER(S); _ 8. Transporter#1:(Acknowledgment of receipt of materials) Agent: Company:, D't' Address: IRO -) t t> _ Phone:t-r))-?b-?)F5t) Signature: Date: 9. Transporter#2:(Acknowledgment of receipt of materials) Agent: • Company: • Address: Phone: Signature: Date: • DISPOSAL:(Certification of receipt of asbestos materials covered by this manifest,except as noted in item 11 below.) 10. Waste Disposal Site: Name and Title: Date: Signature: Phone: 11. DISCREPANCY SPACE:(Add attachments as needed) • • (Revised 6/03) •