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Front Range Landfill <br />FRONT RANGE LANDFILL <br />PO Box 320 <br />Erie, CO 80516 <br />Weighed: Jo C <br />BILL TO: 11234 <br />PALMETTO ENVIRONMENTAL <br />4995 YORK ST <br />DENVER CO 80216 <br />Vehicle ID: <br />Reference: FRL -14 -055 <br />Grid: FRL -WK1 <br />NOTES:: 'COLORADO FLAGSTONE <br />YARDS:: 4301 N COUNTY RD 27 <br />PO# :: LOVELAND, CO 80538 <br />DATE IN: 09/02/2014 TIME IN: 16:18:18 <br />DATE OUT: 09 /02/2014 TIME OUT: 16 :18:18 <br />INBOUND TICKET Number: <br />SCALE 1 GROSS WT. <br />MANUAL TARE WT. <br />NET WEIGHT <br />Qty Description <br />10.00 SW -Yard <br />TICKET AMOUNT: <br />X <br />03- 01029035 <br />52760 LB <br />23440 LB <br />29320 LB <br />Amount <br />140.00 <br />!ARDOUS WASTE <br />MANIFEST <br />Manifest Number: 0522 <br />Approval Number. -A <br />Expiration Date: <br />Generator Information (generator to complete) ' <br />Site Name: Z°° <br />Address:` / ) A)1'0 ,Qf <br />�. City, State: s, iy- Zip: ' �- <br />Tons Contact Perso �- <br />Phone # L x /17' Fax Q <br />140.00 me material represented on the Special Waste Application identified by the above Special <br />lvered to the transporter on the shipment date reWenced below. <br />:) Signature of Generator's Authorized Agent Shipment Date <br />I /WE THE UNDERSIGNED, CERTIFY THAT THE <br />WASTE DELIVERED FOR DISPOSAL IS <br />NON - HAZARDOUS SOLID WASTE MATERIALS. <br />ransporter Information (transporter to complete) 1 <br />Important Notice <br />Disposal facility below must be <br />notified in ADVANCE before delivery <br />of waste with SPECIAL HANDLING <br />instructions. <br />al ,,� herby warrant that the above material was picked up at the generator site <br />Operating Hours: M-F 6am -5 PM, Sat 6am -2p. �-'� listed above and delivered without incident to the destination listed below. <br />PHONE: 303- 673 -9431 <br />r - <br />ame of Driver' (prin / type) Signature of Driver Date <br />Section 3 Destination Information (disposal facility to complete) <br />Front Range Landfill e <br />1830 WCR S POS 320 Waste Codes Volume Received Ticket #/ <br />Erie, CO 80516 Yards Tons 117', Other <br />Phone: 303 -573 -9431 Grid Elevation <br />Fax: 303-673-9432 Charge To e— - j <br />. f <br />Landfill Authorized Ag t Name (print / type) Signature of Landfill's Aut1horized Arent Date <br />Q---) The material delivered above was received at the landfill. <br />white..°Landfill Yellow: Generator Pink: Transporter Gold: Consultant <br />