Laserfiche WebLink
CW! <br /> NON-HAZARDOUS 1 Generator ID Number 2 Pape 1 of 3 Emergency Response Phone 4.Wale Trackkp Number <br /> WASTE MANIFEST N A, _ 800-424-9300 1 264280 <br /> 5,Generator's Name and Mailing Address Generator's Project Address(11 different than mailing address) <br /> C'A Con-0-,CA;r►9 20 G 6640 S , Yo ;civ so-ft4 .. FG Ave, N.,tdio Go, YcotZ <br /> G-J; .64,- )so C;v�41%;oJ Co <br /> Generato•s Phone _713, <br /> 6.Transporter 1 Complete G-impany Name and Address Transporter Phone <br /> SC 0 CGn fro Gel•'eA 1:no 6 4SG_. S Zcde,•At- r4 S4e ES,l2CCA+-AA; 1 -Y94 71/ <br /> 7.Transporter 2 Comp ete Company Nam#fnd Address Transporter Phone <br /> 8.Designated Disposal Facifty Name and Site Address Facility's Phone: <br /> MIDWAY LANDFILL <br /> 8925 RANCHO COLORADO BLVD <br /> FOUNTAIN CO 811817 <br /> 9.Waste Shipping Name,Description 6 Prclae Number No.o.CartWners o Total 12 doll <br /> Type Orantlty WtJtdor. <br /> 1 <br /> cc <br /> 5 Ix C& <br /> e6lGL <br /> w • t^e <br /> Z <br /> W <br /> c7 <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 BA to A Amoam NeWber <br /> Customer Acd#: Customer Name: <br /> 15 Contractor.'Generator CertilMat on <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 KB's or radioactive materials. <br /> Generator's/ONeror's Prir ted/Typed Name Signahur WE year <br /> cc W 16.Trans er Acknowledgement I Receipt of Materials <br /> ¢ Transporter 1 Prirted/ryped Name Signature Month Day y6u <br /> Transporle 2 Primed/Typed hatSlgmat Month Day Year <br /> 17 Specal Handling instructions <br /> 18 Disuepancy Indication Space: 19 Ticket/ <br /> W <br /> _; Irrtiats of Persor noting discrepancy Signature Date <br /> W <br /> 20 Management Mettiod/Locadon <br /> W <br /> O <br /> Landfill Monofill location: <br /> 21 Designated Fac: ry Owner or Operator:Certification of receipt of materials covered by the manifest except as noted.n Item 18 <br /> nted: Fed Nar. S nature Month Day Yes+ <br /> T69 BLC-O 6 10498(Rev.9/14) DESIGNATED FACILITY TO GENERATOR <br />