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CVW <br /> ------------ <br /> NON-HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Waste Tracking Number <br /> WASTE MANIFEST NJ A 800-424-9300 1 268072 <br /> 5.Generator's Name and Mailin Address Generator's Project Address(if different than mailing address) <br /> I ELLURIDE STONE COMPANY T ELI.URIDIa STONE COMPANYPO BOX 355�J TELLURIDE CO 81435 I YCfcs1 ROALtTELLURIDE CO 81435 <br /> Generator's Phone: 970 728-6201 <br /> 6.Trans er 1•Complete Cgmpany Name and Address Transporter Phone <br /> 'ate D Boor c35,5 D 70 <br /> 7.Transporter 2:Complete Company Name and Address / MM r/r'`J/� G U / 0i9P3,u Transporter Phone <br /> 8.Designated Disposal FacilityName and Site Address (1 Y /1 GJ Facility's Phone: <br /> MONTROSE COUNTY LANDFILL <br /> (5NtRW CC5$i 01 <br /> 9.Waste Shipping Name,Description,8 Profile Number <br /> 10.Containers 11.Total 12.Unit <br /> t r No. Type Quantity wtivol. <br /> 1. NO <br /> a (HYDRAULIC OIL IMPACTED SOIL/DEBRIS) <br /> w 123642CC <br /> Z p, <br /> iyr <br /> 0 <br /> 13. Regulatory Agency: Colorado Department of Public Health and Environment Emergency Notification: <br /> 4300 Cherry Creek Drive South CHEMTREC(800)424-9300 <br /> Denver,Co 80222-1530 24-hour Toll Free Number <br /> 14. Bill to&Account Number. <br /> CustomerAcct#E M 314 Customer Name:TELLURIDE STONE COMPANY <br /> 15 Contractor/Generator Certification: <br /> I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified, <br /> packaged,marked and labeled/placarded,and are in all respects in proper condition for transportation according to applicable national and state <br /> governmental regulations. <br /> I hereby certify that the above described waste is not a hazardous waste defined by federal,state or local regulations and does not contain regulated <br /> quantities of PCB's or radioactive materials. <br /> Generator's/Offeror's Printedflyped Name Signature Month Day Year <br /> &f3j <br /> cc I X I <br /> w 16.Transporter Acknowledgement of Receipt of Materials a �� <br /> O AeWq <br /> ed/ryped Name Sign Moyer Day Year <br /> aGt/ 1u, <br /> W - <br /> T rter 2 d p a Signature Month Day Year <br /> cc <br /> 17.Special dbng Instructions <br /> ~ 18.Discrepancy Indication Space: 19.Ticket# <br /> -.1 <br /> V ' <br /> LL / <br /> C <br /> W - <br /> F- <br /> Z Initials of Person noting discrepancy Signature Date <br /> N20.Management Method/Location <br /> CA f <br /> O <br /> Landfill Monofill Location: p;G t <br /> 21.Designated Facility Owner or Operator.Certification of receipt of materials covered by the mjPh9fTx-c-e0Ns noted in Item 18 <br /> Printedlryped Name Signa re Month Day Year <br />