City Hall Asbestos RemovalBUTLER COUNTY LANDFILL /'
3588 R Road
David City, NE 68632
402-367-4662
Owners Name:
City of Blair
225 South 16th Street
Blair, NE 68008
Work Site Reference:
See Attached Waste Shipment Record(s)
ENCLOSED MANIFEST(S) FOR YOUR RECORDS:
Enclosed are manifest(s) for waste brought in for disposal to our facility by an asbestos hauler/company.
Address of Disposal:
Butler County Landfill
3588 R Road
David City, NE 68632
Butler County Landfill is required by 40 CFR Part 61, Subpart M - National Emission Standard for
Hazardous Air Pollutants for Asbestos, §61.145 to do the following:
(1) As soon as possible and no longer than 30 days after receipt of the waste, send a copy of the signed waste
shipment record to the waste generator.
(2) Upon discovering a discrepancy between the quantity of waste designated on the waste shipment records and the quantity
actually received, attempt to reconcile the discrepancy with the waste generator. If the discrepancy is not resolved within 15 days
after receiving the waste, immediately report in writing to the local, State, or EPA Regional office responsible for administering the
asbestos NESHAP program for the waste generator (identified in the waste shipment record), and, if different, the local, State, or
EPA Regional office responsible for administering the asbestos NESHAP program for the disposal site. Describe the discrepancy
and attempts to reconcile it, and submit a copy of the waste shipment record along with the report.
Please retain for your records.
Thank you,
Annette Snyder
WASTE SHIPMENT RECORD
Hour Response Telephone Number
( 402 ) 731-7171
1. Work Site Name and Mailing Address:
Owner's Name:
Owner's Phone #:
City of Blair Building
City of Blair
225 South 16' Street
225 South 161h Street
( 402 ) 426-4191
Blair, NE 68008
Blair, NE 68008
2. Operator's Name and Address:
Operator's Phone #:
McGill Company, Inc. LOAD # Job # 15-1097
4204 South 331d Street
( 402 ) 731-7171
Omaha, Nebraska 68107-1419
3. Waste Disposal Site (WDS) Name, Mailing Address, and Physical Site Location:
WDS Phone #:
Butler County Landfill
3588 "R" Road
( 402 ) 367-4662
L
David City, Nebraska 68632
0
4. Name, and Address of Responsible Agency:
+�
Nebraska Department of Health — Asbestos Division
iv
P. O. Box 95007
L
Lincoln, NE 68509-5007
0
5. Description of Materials:
6. Containers:
7. Total Quantity:
No. Type
m3 (yd 3)
Asbestos, 9, NA2212, III, RQ
c�
Asbestos Friable
8 Drums
Asbestos Non -friable
1 Bag 8 Bundles
8. Special Handling Instructions and Additional Information:
9. 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 & Title
Signature
Month Day Year
Jim Lynch Files Manager
8 20 2015
10. Transporter 1 (Acknowledgement of Receipt
M ials):
Printed/Typed Name & Title
atu}re
Month Day Year
w
Butler County Landfill
Jig
/
Svc ��J�%'
'-
Address and Telephone No.
0
(402) 367-4662
a
3588 'T Road, David City, NE 68632
0
11. Transporter 2 (Acknowledgement of Receipt
Materials):
Printed/Typed Name & Title
Signature
Month Day Year
0
Address and Telephone No.
12. Discrepancy Indication Space:
0
a
13. Waste Disposal Site Owner or Operator:
0
Certification of receipt of asbestos materials covered by this manifest Hour Minute
°'
except as noted In item 12.
V)
Time Landfill Received Load:
Pri ted/7y
Na &
Title
i nature
Month Da Year
)
)ed
15' White Copy — Landfill 21d White Copy- Operator
* A copy of the "Landfill Dump Ticket" must be attached to the Waste Shipment Record "Operator" copy and forwarded to the above #2 listed address.