2014-09-08_INSPECTION - M1985210

• Permit No: M1985210
• IBM Index Class Name: INSPECTION
• Doc Date: 9/8/2014
• Doc Name: Corrective action documentation
• From: Rocky Road Investments
• To: DRMS
• Email Name: MAC
• Media Type: D
• Archive: No

Manifest Number. 0520
NON - HAZARDOUS WASTE Approval Number.
WAM C" MOOS INC.
r. MANIFEST
with#&r te• Expiration Date:
Section 1 Generator Information (generator to complete)
Generator Name:
` , v r. t� `
! = F y
�, ;V'
Site Name:
V
'
J
Address:
�;� ;.VI
P Irk.
Address:
-� G!�
c °,, �., k
P,.0 .
City, State: ° $:y City, State: 4 w e ` ; N � C o
a
Zip: s' S Zip: 777
Contact Person:, Contact Person: 44 L k �r
Phone #:3,,) `r ? 5? 1 �jFax: Phone #: SPI _ S 7 1 DFax:
Common Name of Waste: +gyp. �' °'3 9 .�� �' .� ► Consultant:
b. ; Address: S1 r e(?$
Description of Waste: Pe I i e uvr ° try C s a s. City, State: e tA v c r, 0
j i, ,� E �= Zip: 5?02- i 6
Disposal Volume Yards Tons Contact Person: V�� zl 9b {.� ( A
Other � Phone #: ''` � r�
Fax: a° �' JUH q
I hereby warrant that the above material is the same material represented on the Special Waste Application identified by the above Special
Waste Approval Code and such material s delivered to the transporterbn the shipment date referenced below.
GeneraWs Authorized Agent Name (print / type) Signature,of Generator's Authorized Agent Shipment Date L
Section 2 Transporter Information (transporter to complete)
Transporter Name: �1 4
Address:
City, State: °� �,►.�
Zip:
Important Notice
Disposal facility below must be
notified in ADVANCE before delivery
ofwaste with SPECIAL HANDLING
�
&by warrant that the above material was picked up at the generator site
Phone M _ — . a —) - a listed above and delivered without incident to the destination listed below,
ame of Dn (print / type) Si atum of Driver Date
Section 3 Destination Information (disposal facility to complete)
Front Range Landfill
1830 WCR 5 POB 320 Waste Codes Volume Received Ticket # / _
Erie, CO 80516 ,
YardsL_ Tons , :. , . -Other
Phone: [phone]
Fax: 303 - 673 -8432 Charge To Grid - Elevation
Landfill Authorized Agent Name (print / type) Signature of Landfill's Authorized Agent Date
j I'he material delivered above was received at the landfill.
White: Landfill -, Yellow: Generator Pink: TiatrsPorer'' Gold: Consultant