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I ' <br />Manifest Number: a 0525 <br />ZARD O U S WASTE Approval Number. <br />us, w r <br />MANIFEST Expiration Date: r a <br />Section 1 Generator Information (generator to complete) <br />Generator Name: a � Site Name: ( = F, <br />Address: �-/ ' 7 Address: -%) <br />City, State: <br />Zip: �. <br />City, State: Z—a s s s_4 l <br />Zip: . !� - 21 W <br />Contact Person: �� Contact Person: -� <br />Phone , Fax: Phone #. Fax: <br />Common Name of Waste: ' t Consultant: �;,-) Isle 44,, , d i <br />.AA,J f-, ("C A � Address: <br />B T <br />Description of Waste .�c�� ►- LAM-C, C., ,p,� City, State: , , <br />.® Zip: <br />Disposal Volume Yards Tons Contact Person: -, a <br />Other Phon#l�� F <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 />Generators- uthorized Agent Name (print / type) <br />Signature of Generator's Authorized Agent <br />� dp <br />SKIpment Date <br />Section 2 Transporter Information (transporter to complete) <br />Transporter Name: 44). <br />�lf°t�.�.l�' o A �, r� Important Notice <br />Address -� Disposal facility below must be <br />notified in ADVANCE before delivery <br />of waste with SPECIAL HANDLING <br />City, State: _s��s instructions. <br />Zip: <br />I herby warrant that the above material was picked up at the generator site <br />Phone # °'` listed above and delivered without incident to the destination listed below. <br />Name of 146ver (print 7 type) '° P ignature 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 Ticket #,-- <br />Eris, CO 80518 • Yards i Tons Other <br />Phone: 303 - 673 -9431 Grid Elevation <br />Fax: 303 - 673 -8432 Charge To <br />Landfill Authori 1 Agent Name (print / type) Signature of dfill's Authorized Agent Date <br />�,\ The material delivered above was received at the landfill. <br />White: L�dfill Yellow: Generator Pink: Transporter Gold: Consultant <br />