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, <br />R <br />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: 09/04/2014 TIME IN: 16:26:29 <br />DATE OUT: 09/04/2014 TIME OUT: 16:26:29 <br />ZARDOUS WASTE <br />MANIFEST <br />Manifest Number: 0525 <br />Approval Number. 7,, <br />Expiration Date: m <` <br />Generator Information (generator to complete) <br />u <br />Site Name: <br />.i— 7 Address. ! `9 <br />y <br />City, State: A 4 L2, � a <br />- Zip: <br />Contact Person: Z <br />Phone # Fax: <br />Consultant: P1114& Alt, "_eta L -�.. tyk <br />(° - 1.% Address: dP/2` � -- <br />e <br />INBOUND TICKET Number: 03- 01030084 4re� City, State: <br />SCALE 1 GROSS WT. 53960 LB `� Zip: i <br />MANUAL TARE WT. 23880 LB <br />NET WEIGHT 30080 LB Tons Contact Person: <br />Q a <br />Qty Description Amount Phon -If. a � %/-7 Fax: `` '- � ` <br />10.00 SW -Yard 140.00 <br />is material represented on the Special Waste Application identified by the above Special <br />TICKET AMOUNT: 140.00 rered to the transporter on the shipment date referenced below. <br />Signature of Generator's Authorized Agent Shipment Date <br />X ansporter Information (transporter to- complete) <br />I /WE THE UNDERSIGNED, CERTIFY THAT THE <br />WASTE DELIVERED FOR DISPOSAL IS <br />NON - HAZARDOUS SOLID WASTE MATERIALS. <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 />s listed above and delivered without incident to the destination listed below. <br />Operating Hours: M -F 6am-5 PM, Sat 6am -2pm <br />PHONE: .303-673-9431 Aln <br />Name of -ver (print l type) ►gnature of Driver, Date <br />Section 3 Destination Information (disposal facility to complete) <br />Front Range Landfill d <br />1830 WCR 5 POB 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 I, <br />Landfill AuthOH71d Agent Name (print / type) Signature of 4ndfill's Authorized Agent Date <br />The material delivered above was received at the landfill. <br />- White: dfill Yellow: Generator Fink: Transporter Gold: Consultant <br />