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NON- HAZARDOUS WASTE <br />WMrE CoNNFt --rloNs INc. MANIFEST <br />Cwrmrst tl� e�wa t` <br />Manifest Number: <br />Approval Number. <br />Expiration Date: <br />Section 1 a Generator Information (generator to complete) <br />veuerat.ur frame: <br />Address: _"2501 <br />City, State: Q <br />Zip: 3,')538 <br />0518 <br />d <br />bite dame: <br />Address: c-4 3. -�! iV -� O L, - <br />City, State: Lt o0 o - <br />Zip: "S 3 S <br />Contact Person: �,, �� ,, � . A 1' I Contact Person: <br />4 l <br />Phone M 3j3-1-)&1 - .37- 13F= Phone #: <br />Common Name of Waste: r' : k , ° i ,� f ,1 i Consultant: <br />Address: <br />- - f Fax: <br />pa1me.14,, v, vti <br />i s V ' <br />f Description of Waste: ' b E mCity, State: Qe <br />Zip: 4 <br />Disposal Volume Yards ❑ Tons Contact Person: \j V\ DY <br />Other F Phone #: _`�� a �° ! 1 Fax: =J-LI _50H <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 Authorized Agent Name (print J type) <br />.r <br />Signature of Generator's Authorized Agent <br />S*ment Date <br />Section 2 Transporter Information (transporter to complete) <br />Transporter Name: _ 1k7-� ®` - t Important Notice <br />Address: Disposal facility below must be <br />notified in ADVANCE before delivery <br />City, State: of waste with SPECIAL HANDLING <br />Zip: ;- instructions. <br />I herby warrant that the above material was picked up at the generator site <br />listed above and deliver without incident to the destination listed below. <br />y,= —s ___1 016iver 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 />Erie, CO 80616 Yards :) Tons r A Other <br />Phone: 303 - 673 -9431 <br />Fax: 303 -673 -9432 Charge To • j 1 Grid Elevation <br />Landfill Authorized Agent Name (print / type) Signature of Landfill's Authorized Agent Date <br />The material delivered above was received at the landfill. <br />White: Landfill, Yellow: Generator Pink: Transporter Gold: Consultant <br />