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VONICO II, LLC. <br /> J/,, 09-4 / PHONE: 763-262-8662 FAX:763-262-3299 <br /> t/MPCA PERMIT SW580 . 6 <br /> r 9 <br /> ASBESTOS - CONTAINING MATERIAL TRANSPORT AND DISPOSAL MANIFEST <br /> �,/ PROFILE #: /6 _��('� I <br /> •,v� [� <br /> 1. Work Site Name ��'p') �6/w6 <br /> Address i i. Lr.l. , ,': A ' .f�1__elr 3. Waste Disposal Site VONCO II,LLC. . <br /> City,St.,Zip(9 4 Mailing Address 15301 -140th Ave.S.E. <br /> City,St.,Zip Becker,MN 55308 <br /> Owner's Name <br /> -� Physical Site Location 2.5 miles west from Co.Rd.11' <br /> Owner's Phone No.C � !/ ^' (Be Specific) on Sherburne Ave.at Jct-of <br /> \ , ! 140th Ave.S.E. <br /> G 2. Abatement Contractor <br /> �,, � ....r1.1: 0/3 <br /> .. O 3 V <br /> L� <br /> 8 f{f� <br /> E Address . g g� ._ S�1 4. Responsible Agency MN Pollution Control Agency <br /> N City,st.,zip ,s-c.r Pt A-UL_- 1(,1. 07 Address 520 Lafayette Road <br /> V-7.314<302---- <br /> City,St.,Zip St.Paul,MN 55155-3898 <br /> EOperator's Phone 6 <br /> R 5. Description of Materials 6.Containers(No.-Type) 7.Total Quantity(moor yd,) <br /> T sir ----27i7 P0%94— l 6,41. —_ ,z <br /> 0 <br /> R (---7-, ----)-3) <br /> 8. Special Handling Instructions and Additional Information <br /> • <br /> 9. ABATEMENT CONTRACTOR'S CERTIFICATION:I hereby declare that the contents of this consignment are fully and accurately <br /> I described above by proper shipping name and are ciassifiesl, packed, marked, and labeled, and : e in all respects in proper <br /> condition for transport by highway according to ,.plicable International and governmental regulatio :. <br /> Name&Title(Printed or Typed) I _ , rs:� e... Signature .1 44 L Da 0%3 <br /> I <br /> T 10. Transporter 1 (Acknowledgementnof rrec@Ipt of materials) - <br /> AName /Title / - A/C • Signature ! i Date2 27 3 <br /> N Address L llezb vg rr I"k 4,,,,5_ksy:St.,Zip 9Phone No. 22 "- D <br /> 7-11 <br /> 11. Transporter 2(Acknowledgement of receipt of materials) <br /> T NameTTitle Signature Date <br /> E Address City,St.,Zip Phone No. <br /> DISPOSAL SITE 13. Waste Disposal Site Owner or Operator:Certification of receipt of asbestos <br /> 12. Discrepancy Inds atlon Space materials covered by this manifest except as noted in Item 12. <br /> 5a <br /> Name/Title(Printed 6 jy11' <br /> Ticket# Tons ('blYerds _ <br /> E N Elev. Signature ea_. 2'Z t'3 <br /> CONTRACTOR-WHITE TRANSPORTER-CANARY WASTE DISPOSAL SITE-PINK GENERATOR/OPERATOR-GOLD <br /> . .. . _ – <br /> • <br />