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IL <br />Front Range Landfill <br />FRONT RANGE LANDFILL <br />p0 Box 320 <br />Erie, CO 80516 <br />weighed: Jo C <br />BILL TO: 11234 <br />PALMETTO ENVIRONNENTAL <br />4995 YORK ST <br />DENVER CO 80216 <br />Vehicle ID: <br />Reference: FRL-14 -055 <br />a �1 <br />Grid: FRL -WK1 <br />COLORADO FLAGSTONE <br />NOTES :: <br />YARDS:: 4301 N COUNTY RD 27 <br />PO #:.. LOVELAND, CO 80538 <br />DATE IN: 09/03/2014 TIME IN: <br />TIME OUT: <br />11:29:29 <br />11:29:29 <br />DATE OUT: 09/03/2014 <br />INBOUND TICKET Number: 03- 01029314 <br />SCALE 1 GROSS WT. <br />59080 LB <br />MANUAL TARE WT. <br />23440 LB <br />35640 LB <br />NET WEIGHT <br />gty Description <br />Amount <br />140.00 <br />10,00 SW -Yard <br />TICKET AMOUNT: <br />140.00 <br />C <br />4' by <br />►ZARDOUS WASTE <br />MANIFEST <br />Manifest Number 0523 <br />Approval Number. F/1 / <br />Expiration Datd:• / <br />Generator Information (generator to complete) <br />Site Name: <-, • o��" �) "L <br />Address: ? 4� <br />`> >� City, State:' <br />Zip: <br />Contact Person: <br />Ph e Fax: <br />► Consultan ' a <br />R 7" t,,•,S Address: ` <br />� J' d r M %City, State: _ <br />law) a a 1.1 Zip: I <br />Tons Contact Person:; <br />tedal represented on the Special Waste Application identified by the above Special <br />:o the transporter on the shipment date referenced below. <br />Signature of Generator's Authorized Agent <br />Shipment Date <br />Drter information (transporter to complete) <br />X� <br />a �1 <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 />�- I herby warrant that the alcove material was picked up at the generator site <br />Phone #: -� C ''3 listed above and delivered without incident to the destination listed below. <br />` game of Driver not / type) Sign of Driver Date <br />F7Section 3 Destination Information (disposal facility to complete) <br />Front Range Landfill <br />1830 WCR 5 POS 320 Waste Codes Volume Received Ticket # <br />Erie, CO 80516. Yards_ Tons Other <br />Phone: 303 - 673 -9431 Grid Elevation <br />Fax: 303 - 673 - 9432, Charge To <br />Landfill Authorized Agent Name (print / type) Signature of Landfill's Authorized Agent Date <br />The material delivered above was received at the landfill. <br />White �isnd Yellow: Generator Pi :Transporter Gold: Consultant <br />