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Manifest Number: <br />0519 <br />a......- nHLARD0US WASTE Approval Number. r If'/ -'° <br />WAM CON)._ — ..,/NS INC. �. <br />r'anwaU*AskeFwgw MANIFEST Expiration Date: <br />Section 1 Generator Information (generator to complete) <br />Generator Name: ti V, C <br />Address: - ' 6 ,� ti, '``'�, k <br />City, State: ,k <br />Zip: 0 S �� <br />Site Name: I - -A tA 9 ! a , V C, <br />.J 4 <br />Address: Lj C—, <br />City, State: <br />Zip: lam, s <br />Contact Person: <br />oh <br />J <br />Contact Person:v <br />Z, rF <br />Phone #: `: 3 <br />Fax: <br />Phone #: u u ';- - <br />13 Fax: <br />Common Name of Waste: i )�+ ,A ��. ��' c -S�t l <br />I•a � -r i .�t-�� <br />Consultant: R� lye e 1.1 ) L. V- v o vl pro QV J' 9 <br />Address: W! q q L, a. � _� ice 4 <br />Description of Waste: vli J Q �'A 14 v � i �_ ' L' City, State: 0 e A 4 c >r- C0 <br />Zip: So 16 <br />Disposal Volume p! Yards Tons <br />Other 17 <br />Contact Person: Vk bl Li -� <br />Phone #: -)y'� �- t��'Fax: <br />" a� <br />L`,- <br />I hereby warrant that the above material is the some material represented on the Special Waste Application identified by the above Special <br />Waste Approval Code and such material was delivered to the transporter on the shipment date referenced below. T <br />Generator's Authorized Agent Name (print / type) <br />Signature of Generator's Authorized Agent Sliipment Date <br />Section 2 _ Transporter Information (transporter to complete) <br />Transporter Name: <br />Address: <br />City, State: ° t I <br />zip:;" <br />Important Notice <br />Disposal facility below must be <br />notified in ADVANCE before delivery <br />of waste with SPECIAL HANDLING <br />instructions. <br />��r� ' ' I herby warrant that the above material was picked up at the generator site <br />Phone iF' ": listed above and delivered without incident to the destination listed below. <br />d P ic� <br />Na me of Drip <br />Signature of Driver �- Date <br />Section 3 Destination Information (disposal facility to complete) <br />Front Ransae Landfill <br />1830 WCR 5 POB 320 <br />Erle, CO 80516 <br />Phone: 303 -673 -9431 <br />Fax: 303 -673 -9432 <br />Waste Codes I I <br />Charge To <br />Landfill Authorized Agent Name (print / type) <br />White. Landfill - Yellow: Generator <br />Volume Received Ticket # t <br />Yards Tons ,. , ' . , Other <br />Grid Elevation <br />Signature of Landfill's, Authorized Agent Date <br />The material delivered above was received at the landfill. <br />Pink: Transporter Gold: Consultant <br />