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i <br />WAsm CONIYt..C'riONSINC. <br />w"j*' <br />NON - HAZARDOUS WASTE <br />MANIFEST <br />Manifest Number: 0517 <br />Approval Number.; <br />Expiration Date:"$ <br />Section 1 Generator Information (generator to complete) <br />Generator Name: <br />Address: --6 ;-)I tJ (,wj, ',y, P J I I <br />V <br />City, State: L uy r ► ,C3 <br />Zip:,a S <br />Site Name: C -zo 1 sia t, , 9 7, r 1:, � _s � y r- <br />Address: "-i) ,N6 N u, v 1� <br />City, State: e . ,,� ►c.. ),� <br />Zip: r,� <br />Contact Person:; Contact Person: } ,� <br />Phone #: 594-S213 Fax: <br />Phone #: u -52 1 Fax: <br />Common Name of Waste: Consultant: rA l m e 4 $t, �_ t, v e u <br />r, kkc .r b Address: �1 g 1'-Q ' <br />Description of Waste: � r -� t' �, F� �.� n�r_�Irv� City, State: be 1- 0 <br />Disposal Volume Yards Tons Contact Person: J 0�� <br />0therF_1 <br />ca <br />Phone #: �U?� -; d 4 ° Fax: " �-� -501-1 <br />1 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 />Generator's Authorized Agent Name (print / type) Signature of Generator's Authorized Agent <br />Shipment Date <br />Section 2 Transporter Information (transporter to complete) <br />Transporter Name: ,aAA _ , r. i a <br />Address: <br />City, State: _C <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 />r I herby warrant that the above material was picked up at the generator site <br />Phone #: -0 listed above and delivered without incident to the destination listed below. <br />)A tjr <br />Name of Dn r (print/ type) Sign of Driver Date <br />Section 3 Destination Information (disposal facility to complete) <br />Front Range Landfill <br />1830 WCR 5 POS 320 Waste Codes Volume Received Ticket # <br />Erie, CO 80516 Yards Tons Other <br />Phone: 303 - 673 -5431 Grid Elevation <br />Fax: 303 - 673 -9432 Charge To <br />Landfill Authorised Agent Name (print / t)pe) Signature of,Landfill's Authorized Agent Date <br />The material delivered above was received at the landfill. <br />White:AAndfill Yellow: Generator Pink. Transporter Gold: Consultant <br />Sn <br />.r <br />