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

y�•
WAS"
_RDOUS"WASTE
MANIFEST
Manifest Number: 0516
Approval Number. �'°° S l T
Expiration Dated t'
Section 1 Generator Information (generator to complete)
Generator Name: rj i b v &' s- 6 k ¢ "3 " Site Name: �� �d i° �� ® " ' � 1'.V1 e_
Address: "13 0 1 NJ y, P A. Address: ' i 3,01 0 C � a _ t �A � �F � �
City, State: L O
Zip: " 3
City, State: L ;V e t LA A L :roe
" y
Zip: � o
Contact Person: DOLA Ck Contact Person:
Phone #: 3 o � ° �� ° 21, ax: Phone #: ' 6l - - 1'3 Fax:
Common Name of Waste: �� � � 1 t mj v� 4 ,9 ,, - w l Consultant: to ! � e
� �c• �,,� s�a� rAb +�.�� Address: -111S a.pr "C4
Description of Waste: "J� ' �� �' sac n r �v� City, State:
.i e �k 'S4r t Zip:
Disposal Volume Yards Tons
Otherf—I
Ue" "'(er e C 0
16
Contact Person: d,J o� h br_ o r� s
Phone #:[phone] Fax• 303- 5 34 -.S34 q
I hereby warrant that the above material Is the same material represented on the Special Waste Application idenfified by the above Special
Waste Approval Code and such material was delivered to the transporter on the shipment date referenced below.
Generator:�Authorized Agent Name (print / type)
1 �
Signature of Generator's Authorized Agent
Shipment Date
Section 2 Transporter Information (transporter to complete)
Transporter N
City, State:_ a;, )
Zip:
Important Notice
Disposal facility below must be
notified in ADVANCE before delivery
of waste with SPECIAL HANDLING
instructions.
j"
al I herby warrant that the above material was picked up at the generator site
PhO a #: V} listed above and delivered without incident to the destination listed below.
ame of Driver tint / type) Signature _ Driver Date
Section 3 Destination Information (disposal facility to complete)
Front Range Landfill
1830 WCR 5 POB 320 Waste Codes /° 7; Volume Received Ticket # ,
Erie, CO 80516 Yards , Tons,_ ; Other
Phone: [phone] ,�a Grid Elevation
Fax: [phone] Charge To a„ k, ; � r �s
"
Landfi ll Authorized Agent Name (print / type) Signature of L arrdfill's Authorized Agent Date
The material delivered above was received at the landfill.
White: Lanldfilt Yellow: Generator Pink: Transporter �, Gold: Consultant
1.