ASN 4 ASBESTOS WASTE SHIPMENT REPORT FORM PLEASE PRINT OR TYPE. If you have questions, contact your local DEQ Regional Office in Portland 503-229-5364, Salem 503-378-5086, Medford 541-776-6107, Coos Bay 541-269-2721 ext. 222, Bend 541-633-2019, or Pendleton 541-278-4626. WASTE GENERATOR: (Contractor, Facility, or Operator) 1. Asbestos removal site name and address: _____________________________________________________________________ Street City/State Contact person: 2. Zip Phone: Contractor/Operator’s name and address: Street 3. County Phone: City/State Waste disposal site: County Zip County Zip Phone: Street City/State 4. Describe asbestos materials: 5. Containers: 6. Total quantity (cubic yards): 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 this Waste Shipment Record Form. Number: Agent: Address: TRANSPORTER(S): 8. Transporter #1: (Acknowledgment of receipt of materials) Agent: Address: Type: Company: Phone: Company: Phone: Signature: 9. Transporter #2: (Acknowledgment of receipt of materials) Agent: Address: Signature: Date: Company: Phone: 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 4/14) Instructions for using DEQ Form ASN 4 Waste Shipment Report Form This form is to be used as a permanent record for documenting asbestos-containing waste materials from removal site to final disposal. The Oregon Department of Environmental Quality (DEQ) regulation that applies to asbestos waste disposal is found in OAR 340-248-0280 and -0290. WASTE GENERATOR SECTION (Numbers below correspond to numbers on the front of this Form) 1. 2. 3. 4. 5. Enter the name and address of the site where the asbestos waste was generated. Enter the name and phone number of the contact person for the contractor, facility, or operator of the asbestos waste generation site. Enter the name, phone number and address of the person performing the asbestos abatement. Enter the name, phone number and address of the disposal site that the waste is taken to. Describe the materials being removed. (i.e. pipe insulation, flooring, roofing, popcorn ceiling material, HVAC system insulation, or nonfriable asbestos.) List the total number of containers and their type. 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): DM DP BA NFC 6. 7. Metal drums, barrels Plastic drums, barrels 6 mil. plastic bags or wrapping Leak-tight containerization for nonfriable asbestos waste material. Give an estimate of the total cubic yards of material. Print clearly the name of the company and their authorized signer. This section of the form must be signed and dated. NOTE: The waste generator must retain a copy of the completed disposal form. WASTE TRANSPORTER SECTION 8. 9. Transporter #1: Acknowledgment of receipt of asbestos waste materials. Print agent and company name, then sign and date. Transporter #2: Acknowledgment of receipt of asbestos waste materials. Print agent and company name, then sign and date. (Revised 4/14) NOTE: If there are more than two transporters attached a new waste shipment form. DISPOSAL SITE SECTION 10. 11. List the name of the waste disposal site, print the name, title and phone number, then sign and date form. This certifies that you have received the asbestos material covered by this manifest. Discrepancy space. This space is used if there is a discrepancy between the amount of the material received by the landfill and the amount of material listed on the waste shipment report form. NOTE: The waste disposal site operator must retain a copy of this form. In addition, asbestos waste disposal regulations require that the Waste Disposal Site operators take the following actions: • Send a copy of the completed and signed Waste Shipment Report Form to the Waste Generator as soon as possible, but no later than 30 days after the waste has been received at the disposal site. • Notify DEQ immediately by telephone of improperly enclosed or uncovered waste. Submit a written report to DEQ the following working day, along with a copy of the Waste Shipment Report Form. • If you discover a discrepancy between the quantity of waste designated on the Waste Shipment Report Form and the quantity of waste actually received, attempt to reconcile the discrepancy with the Waste Generator. You must report, in writing, to DEQ within 15 days after receiving the waste any discrepancies that cannot be reconciled. Submit a copy of the Waste Shipment Report Form with this report.
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