Form SFN58174 "Asbestos Waste Manifest Form" - North Dakota

What Is Form SFN58174?

This is a legal form that was released by the North Dakota Department of Health - a government authority operating within North Dakota. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on December 1, 2005;
  • The latest edition provided by the North Dakota Department of Health;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form SFN58174 by clicking the link below or browse more documents and templates provided by the North Dakota Department of Health.

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Download Form SFN58174 "Asbestos Waste Manifest Form" - North Dakota

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ASBESTOS WASTE MANIFEST FORM
North Dakota Department of Health
Asbestos Control Program
SFN 58174 12/05
I. WASTE GENERATOR
(BUILDING OWNER, BUILDING MANAGER, OR PROJECT CONTRACTOR)
Operator or Contractor Name
Operator or Contractor Address
City
State
Zip Code
Phone Number
Owner Name
Owner Address
City
State
Zip Code
Owner Phone Number
Work Site Name
Work Site Address
City
State
Zip Code
Site Location (floor and/or room number)
Description of Materials
Number of Containers/Bags
Total Quantity (square yards or pounds)
Special Handling Instruction and/or Additional Information
Owner or 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.
Signature of Owner or Operator
Date
II. WASTE TRANSPORTER
Waste Transporter Name
Transporter Address
City
State
Zip Code
Phone Number
Transporter Signature
Date Transported
III. WASTE DISPOSAL SITE
Name of Disposal Site (landfill)
Landfill Address
City
State
Zip Code
Phone Number
Waste Disposal Site Owner or Operator Name
Waste Disposal Site Owner or Operator Title
Waste Disposal Site Owner or Operator Certification: To the best of my knowledge, I hereby declare that the contents of this
consignment are fully and accurately described on this manifest and there are not discrepancies between the amount listed above
and the amount I have received, unless otherwise noted. I also certify there is no improperly enclosed or contained waste.
Signature of WDS Owner or Operator
Date
The owner or operator must submit a copy of this
North Dakota Department of Health
nd
completed form within 10 days of receiving the form
Division of Air Quality, 2
Floor
from the disposal site operator.
918 East Divide Avenue
Bismarck, ND 58501-1947
Return completed form to
Phone: 701.328.5188
Asbestos NESHAP Coordinator:
Fax:
701.328.5185
ASBESTOS WASTE MANIFEST FORM
North Dakota Department of Health
Asbestos Control Program
SFN 58174 12/05
I. WASTE GENERATOR
(BUILDING OWNER, BUILDING MANAGER, OR PROJECT CONTRACTOR)
Operator or Contractor Name
Operator or Contractor Address
City
State
Zip Code
Phone Number
Owner Name
Owner Address
City
State
Zip Code
Owner Phone Number
Work Site Name
Work Site Address
City
State
Zip Code
Site Location (floor and/or room number)
Description of Materials
Number of Containers/Bags
Total Quantity (square yards or pounds)
Special Handling Instruction and/or Additional Information
Owner or 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.
Signature of Owner or Operator
Date
II. WASTE TRANSPORTER
Waste Transporter Name
Transporter Address
City
State
Zip Code
Phone Number
Transporter Signature
Date Transported
III. WASTE DISPOSAL SITE
Name of Disposal Site (landfill)
Landfill Address
City
State
Zip Code
Phone Number
Waste Disposal Site Owner or Operator Name
Waste Disposal Site Owner or Operator Title
Waste Disposal Site Owner or Operator Certification: To the best of my knowledge, I hereby declare that the contents of this
consignment are fully and accurately described on this manifest and there are not discrepancies between the amount listed above
and the amount I have received, unless otherwise noted. I also certify there is no improperly enclosed or contained waste.
Signature of WDS Owner or Operator
Date
The owner or operator must submit a copy of this
North Dakota Department of Health
nd
completed form within 10 days of receiving the form
Division of Air Quality, 2
Floor
from the disposal site operator.
918 East Divide Avenue
Bismarck, ND 58501-1947
Return completed form to
Phone: 701.328.5188
Asbestos NESHAP Coordinator:
Fax:
701.328.5185