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

Front Range Landfill FOR OFFICE USE ONLY
1830 Weld County Road Five
Erie, CO 80516 r' APPROVAL NUMBER.
PH: 303.828.9400 ' d f EXPIRATION DATE:
FX:303.828.9438
SPECIAL WASTE AP PLICATUON APPROVED BY.
Information utilized for completion of this form must originate from an authorized representative of the generator of the waste material.
The infrcmation on this form rrunst he COMPLETELY FILLED OUT TYPE WRITTEN. and the form must be SIGNED BY AUTHORIZED REPRESENTATIVE.
A. PROFILE INFORMATION
1. Q Initial El Recertification, list prior approval number(s): _
2. Have there been any changes to the composition of, or process generating this waste stream that would alter the characteristics of the waste stream?
OYES [9 NO (Updated analysis may be required even if no change to process or composition.)
S. GENERATOR INFORMATION
C. CUSTOMEPt1i811Q.LING INFORMATION
1. Generator Name: Colorado Flagstone
1. Billing Name: Palmetto Environmental
2, Address: 4301 N. County Road 27
2. Address 4995 York Street
City: Loveland County: Lanmer
City: Denver County: Denver
State: CO
Zip: 80538
State: CO
Zip: 80216
3. Site Location (If different) _
3. Contact Name: John Drafts
4. Contact Name: Doug Bachli
4. Phone Number: (303) 825-B117 5. Fax Number:
5 Phone Number: (303) 589 -5213 6. Fax Number:
6. Email Address: mail @paknetto- environmental.com
7 Email Address: sales @coloradoflagstone.com
7. Is there a service agreement on file? ® YES ❑ NO
8. State Facility ID # (if applicable):
8. Agent / Consultant:
9. State Waste Code (if applicable):
9. Letter of Authorization: ❑ YES ❑ NO
D. TRANSPORTEWSFIIPPING INFORMATION
E. WASTE STREAM INFORMATION
1. Name: Colorado Flagstone
1 Common Name of Material or Waste Stream:
Soil contaminated with motor oil
2. Street Address: 4301 N. County Road
City: Loveland I State: CO Zip: 80538
2. Detailed Description of Process or How Generated ,Arill Ad. N:M1 1.111'­'dm:
Soils from area used historically for machinery repair
3. Phone Number: (303) 589 -5213 4. Fax Number:
5. Contact Name: Doug Bache
3 Physical State at 707: 91 Solid ❑ Semi -Solid ❑ Sludge
6. EPA or State Transporter ID #:
❑ Liquid ❑ Powder ❑ Other
7. Designated Landfill(s):
4. Free Liquids: © NO ❑ YES % Liquids:
8. Packaging: ❑ Bulk Solids ❑ Bulk Liquids ❑ Drums ❑ Roll-Off
5. Color: brown 1 6. pH Range:
7. Odor: RA None ❑ Mild ❑ Significant Describe:
Dump Truck ❑ Tank Truck ❑ Vacuum Box ❑ Bagged
9. Estimated Volume: 80
8. Flash Point: ❑ °F ❑ °C _
❑ Tons © Cubic Yards ❑ Drums ❑ Gallons ❑ Other:
9. Reactive. 0 NO ❑ YES with:
10. Shipping Frequency: per: Mn One Time Project
10. State Required Information (if applicable):
❑ Month ❑ Quarter ❑ Year ❑ Other:
F. NON - HAZARDOUS DETERMINATION
1. Attached Document(s) (check all that apply): ❑ Not Applicable H Process Knowledge ❑ MSDS ❑t7 Certified Analytical Report ❑ Exempt Waste
2 If Process Knowledge, provide details: See analytical report
3. If analytical data is attached, is the data derived from testing a representative sample In accordance with 40 CFR 261 and /or other applicable laws?
YES ❑ NO Type of Sample: ❑ Composite Q Grab Analysis Provided: EPA 8015B, 6010, 7470, 8260
4. If Exempt Waste, check applicable item below- ❑ UST Corrective Action -40 CFR 261,4(b)(10) ❑ PCB Bulk Product Waste - 40 CFR 761.62
❑ Oil & Gas E &P Waste - 40 CFR 261.4(b)(5) ❑ RCRA -Empty Containers - 40 CFR 261.7 ❑ Other (provide reference)
G. GENERATOR CERTIFICATION STATEMENT:
I hereby certify that all information contained herein is true and correct, and the material described is properly identified, classified, packaged, labeled, and prepared as indicated I
certify this waste is not hazardous or dangerous as defined by the U.S. EPA, or the state or province of origin. I certify this waste does not contain any regulated radioactive
materials, that all known and suspected hazards have been disclosed, and that the waste is not a regulated hazardous waste by government or local authority, and does not contain
PCB's regulated by TSCA or any other regulatory authority I certify that all samples used for this analysis are representative of the materials described herein. I understand that all
wastes may undergo inspection upon arrival at the designated facility and may be refused if the delivered material does not conform to the description herein Notification will be
provided immediately if there is a change in the composition of, or process generating this waste stream, prior to offering the waste for shipment or management.
AUTHn;171D REPRESEVAVVE NWEIITLE COWAN' NAME
fL7- OfiI�EO REP RESErTATIvE SIGNATURE DALE C01PLETED