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Manifest Number: 0524 <br />HAZARDOUS WASTE Approval Number r jq,-: s' <br />MANIFEST Expiration Date: - s` <br />Generator Information (generator to complete) <br />.� �= <br />_:rator Name: 43 . Site Name: <br />y Address: ° ,%, Address: AJ QA 7 <br />City, State: Q , City, State:' <br />Zip: Zip: <br />Disposal Volume Yards Tons Contact Person: <br />Other F-1 Phone *a.. <br />I <br />I hereby warrant that the above material is the same material represented on the Special Waste Application identified by the above Special <br />Waste Approval Code and such material was delivered to the transporter on the shipment date referenced below. <br />Genemte,Os Authorized Agent Name (print / type) Signature of Generator's Authorized Agent Shipment Date <br />Section Z Transporter Information (transporter to complete) <br />Transporter Name: <br />Address: <br />City, State: <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 above material was picked up at the generator site <br />Phone #: `� +� listed aho a and delivered without incident to the destination listed below. <br />ame of Driver (print / type) S&Wre of Driver Date <br />Section 3 Destination Information (disposal facility to complete) <br />Front Range Landfill <br />1830 WCR 5 POB 320 Waste Codes '� Volume Received Tict <br />Erie, CO 80516 <br />Phone: 303 - 673 -8431 Yards P � Tons -� ether <br />Fax: 303 - 673 -8432 Charge To Grid Elevation <br />Landfill Authorized Agent Name (print / type) Signature of Landfill's Authorized Agent haw <br />The material delivered above was received at the landfill. <br />White: Landfill Yellow: Generator Pink: Transporter Gold: Consultant <br />