Asbestos Waste Shipment Record Form

§ 61.149 40 CFR Ch. 1 (7-1-00 Edition)

Generator
  1. Work site name and mailing
    address

 

     

 Owner's name Owner's telephone number
  1. Operator's name and address
 Operator's telephone number

 
  1. Waste disposal site (WDS) name, mailing address, and physical site location

 

 WDS phone number
  1. Name and address of responsible agency

    2.  
  1. Description of materials
  1. Containers
    No. Type

  1. Total Quantity
    m3 (yd3)
     
     
8. Special handling instructions and additional information

 
  1. 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, packed, marked, and labeled, and are in all respects in proper condition for transport by highway according to applicable international and government regulations.
Printed/typed name and title
Address and telephone no.

 

 Signature Month /Day/ Year

Transporter

 10.  Transporter 1 (Acknowledgement of receipt of materials)
Printed/typed name and title
Address and telephone no.

 

 Signature Month /Day /Year
11. Transporter 2 (Acknowledgement of receipt of materials)
Printed/typed name and title
Address and telephone no.

 

 Signature Month/ Day /Year

Disposal site

 12. Discrepancy indication space

 
13. Waste disposal site owner or operator:
Certification of receipt of asbestos materials covered by this manifest except as noted in item 12.

Printed/typed name & title

 

 		Signature Month/ Day/ Year

 

Instructions

Waste Generator Section (Items 1-9)

  1. Enter the name of the facility at which asbestos waste is generated and the address at which the facility is located. In the appropriate spaces, also enter the name of the owner of the facility and the owner's phone number.
  2. If a demolition or renovation, enter the name and address of the company and authorized agent responsible for performing the asbestos removal. In the appropriate spaces, also enter the phone number of the operator.
  3. Enter the name, address, and physical site location of the waste disposal site (WDS) that will be receiving the materials. In the appropriate spaces, also enter the phone number of the WDS. Enter "on-site" if the waste will be disposed of on the generator's property.
  4. Provide the name and address of the local, state, or EPA regional office responsible for administering the asbestos NESHAP program.
  5. Indicate the types of asbestos waste materials generated. If from a demolition or renovation, indicate the amount of asbestos that is
  1. Enter the number of containers used to transport the asbestos materials listed in item 5. Also enter one of the following container codes used in transporting each type of asbestos material (specify any other type of container used if not listed below):
  1. Enter the quantities of each type of asbestos material removed in units of cubic meters (cubic yards).
  2. Use this space to indicate special transportation, treatment, storage or disposal or Bill of Lading information. If an alternate waste disposal site is designated, note it here. Emergency response telephone numbers or similar information may be included here.
  3. The authorized agent of the waste generator must read and then sigh and date this certification. The date is the date of receipt by transporter.

    4. NOTE: The waste generator must retain a copy of this form.

    Transporter Section (Items 10 & 11)
  4. & 11. Enter name, address, and telephone number of each transporter used, if applicable. Print or type the full name and title of person accepting responsibility and acknowledging receipt of materials as listed on this waste shipment record for transport. Enter date of receipt and signature.

NOTE: The transporter must retain a copy of this form.

Disposal Site Section (Items 12 & 13)

  1. The authorized representative of the WDS must not in this space any discrepancy between waste described on this manifest and waste actually received as well as any improperly enclosed or contained waste. Any rejected materials should be listed and destination of those materials provided. A site that converts asbestos-containing waste material to non-asbestos material is considered a WDS.

    2.  

  2. The signature (by hand) of the authorized WDS agent indicates acceptance and agreement with statements on this manifest except as noted in item 12. The date is the date of signature and receipt of shipment.

NOTE: The WDS must retain a completed copy of this form. The WDS must also send a completed copy to the operator listed in item 2.