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

✓ s
VARDOUS WASTE
MANIFEST
Manifest Number:
Approval Number:
Expiration Date:
Section 1 Generator Information (generator to complete)
rn e
Generator Name:
Address: ,�-�, d
City, State: �= ,c `
Zip:
Contact Person j
Phone # ✓'� �' Fax:
0521
'fir' ., {�• / py'`�
Site Name: " a,-)-" n
Address: /> C�/ � 7C -
City, State: -t,
Zip:
Contact Person:
Ph; Fax:
es
F� �l � vr� ...
Common Name of Waste: �m ar .:�� , consultant:
Address:
Description of Waste• `��f} �� , a,? a �d •, �.l,l City, State:
Zip: � � fo
m
Disposal Volume Yards Tons Contact Person:,
Other F� P ���i
-4-
one # « Fax:
1 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 was delivered to the transporter on the shipment date referenced below.
T
Authorized Agent Name (print / type)
1
Signature of Generator's Authorized Agent
Shipment Date
v
Section 2 Transporter Information (transporter to complete)
Transporter Name:
Address: J
City, State:,/_
Important Notice
Disposal facility below must be
notified in ADVANCE before delivery
of waste with SPECIAL HANDLING
instructions.
I herb warrant that the above material was picked u at the
Phone #�_ t� °�;� y P P generator site
listed abovy and delivered without incident to the destination listed below.
ame of Driver nt /type) Sigruiupdof Drives
Section 3 Destination Information (disposal facility to complete)
Front Ranae LanelRit
1830 WCR 5 POO 320 Waste Codes I
Phone: Volume Received Ticket #
Erie, e: 303 - 673 -9431
80516 Yards / , _ Tons Other
Fax: [phone] Charge To L , Grid Elevation
Landfill Authorized Ageht Name (print / type) Signature of Landfill's Authorized Agent Date
The material delivered above was received at the landfill.
White: Landfill Yellow: Generator Pink: Trari� Gold: Consultant