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

X
I /WE THE UNDERSIGNED, CERTIFY THAT THE
WASTE DELIVERED FOR DISPOSAL IS
NON- HAZARDOUS SOLID WASTE MATERIALS.
Operating Hours: M-F 6am -5 PM, Sat Sam -2pm
PHONE: [phone] r am ;ttver (print / type)
nsporter Information (transporter to complete) w
7
Important Notice
Disposal facility below must be
notifieA in ADVANCE before delivery
of waste with SPECIAL HANDLING
instructions.
I herby wan-ant that the above material was picked up at the generator site
listed above and deliver without incident to the destination listed below.
Signature ver Date 9
Section 3 Destination Information (disposal facility to complete)
Front Range - landfill
1830 WCR 5 POB 320 Waste Codes Volume Received Ticket #
Erie, CO 80516 Yards-L ) Tons . Other
Phone: 303 - 673 -9431 � -- Grid Elevation
Fax: [phone] Charge To : ) 1 � L� ,��y, r
$'
Landfill Authorized Agent Name (print / type) Signature of Landfill's Authorized Agent Date
_l) . The material delivered above was received at the landfill.
White. Landfil Yellow: Generator _ rink: Transporter Gold: Consultant
Manifest Number: 0518
�--�"
►ZARDOUS WASTE Approval Number. Plr /V,d
MANIFEST Expiration Date:
Front Range Landfill
FRONT RANGE LANDFILL
PO Box 320
Generator Information (generator to complete)
Erie, CO 80516
Weighed: Jo C
i Site Name: _ ,V
BILL TO: 11234
^� .' 1 b" 4 i Address: °F 301 N e* 2 y
PALMETTO ENVIRONMENTAL
4995 YORK ST
DENVER CO 80216
s L) City, State:'
Zip:
Vehicle ID:
Reference: FRL -14 -055
Contact Person:; V�{ `
Grid: FRL -Will
j
NOTES:: COLORADO FLAGSTONE
YARDS:: 4301 N COUNTY RD 27
Phone #: ! -(3- -'31° 52' i 3Fax•
PO #:: LOVELAND, CO 80538
Consultant: RA IOA 14,E o'v o
c bhoieM
DATE IN: 09/04/2014 TIME IN:
12:35:38
; t �- � '
'mr 4, d Address: 1 �1 `�!� �- 4 -�
DATE OUT: 09/04/2014 TIME OUT:
12:35:38
INBOUND TICKET Number: 03- 01029913
1;
4 ,a A 1 OCity, State: Rev' J e r
.a • � e' � .� ,i 1 �"u� - 1 �
Zip:
SCALE 1 GROSS WT.
55600 LB
£
MANUAL TARE WT.
23880 LB
Tons Contact Person: Q -)I, V�.
NET WEIGHT
31920 LB
Qty Description
Amount
Phone #: J' 8 6 Fax•`
10.00 SW -Yard
140.00
a material represented on the Special Waste Application identified by the above Special
TICKET AMOUNT:
140.00
fired to the transporter on the shipment date referenced below.
y
Signature of Generator's Authorized Agent ` Shipment Date
X
I /WE THE UNDERSIGNED, CERTIFY THAT THE
WASTE DELIVERED FOR DISPOSAL IS
NON- HAZARDOUS SOLID WASTE MATERIALS.
Operating Hours: M-F 6am -5 PM, Sat Sam -2pm
PHONE: [phone] r am ;ttver (print / type)
nsporter Information (transporter to complete) w
7
Important Notice
Disposal facility below must be
notifieA in ADVANCE before delivery
of waste with SPECIAL HANDLING
instructions.
I herby wan-ant that the above material was picked up at the generator site
listed above and deliver without incident to the destination listed below.
Signature ver Date 9
Section 3 Destination Information (disposal facility to complete)
Front Range - landfill
1830 WCR 5 POB 320 Waste Codes Volume Received Ticket #
Erie, CO 80516 Yards-L ) Tons . Other
Phone: 303 - 673 -9431 � -- Grid Elevation
Fax: [phone] Charge To : ) 1 � L� ,��y, r
$'
Landfill Authorized Agent Name (print / type) Signature of Landfill's Authorized Agent Date
_l) . The material delivered above was received at the landfill.
White. Landfil Yellow: Generator _ rink: Transporter Gold: Consultant