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"MESA <br />COUNTY <br />SOLID WASTE MANAGEMENT <br />3071 Highway 50 <br />Grand Junction, CO 81503 <br />(970) 241-6846 • Fax (970) 242-9434 <br />NON -HAZARDOUS WASTE & ASBESTOS MANIFEST <br />If waste is asbestos waste, complete Sections I, I1, and IV <br />If waste is NOT asbestos, complete Sections I, II <br />15658 <br />( Section I GENERATOR J <br />Generator Name: Generating Location.- <br />Address: <br />ocation:Address: Address.- <br />Phone <br />ddress:Phone No.: Phone No.: <br />Description of Waste Quantity <br />1 <br />2 <br />3 <br />Generators certification: I hereby certify that the above named material is not a hazardous waste as defined by 40 CFR Part <br />261, or any applicable state law, has been properly described, classified and packaged, and is in proper condition for <br />transportation according to applicable regulations. If the waste is a treatment residue of a previously restricted hazardous <br />waste subject to Land Disposal Restrictions, I certify and warrant that the waste has been treated in accordance with the <br />requirements of 40 CFR Part 268 and is no longer a hazardous waste as defined by 40 CFR Part 261. <br />Generator Authorized Agent Name Signature Shipment Date <br />Section II TRANSPORTER <br />Name: Address: <br />Driver Name/Title: (Print/Type) Truck No.: <br />Phone No.: <br />Vehicle License No/State: <br />Driver Signature Shipment Date <br />Section III DESTINATION LANDFILL USE ONLY <br />Site Name: Mesa County Landfill, 3071 Highway 50, Grand Junction, Colorado 81503 <br />Site Disposal <br />Active Face- Landfill ❑ Asbestos Waste Disposal Cell ❑ <br />1 hereby certify that the above named material has been accepted and to the best of my knowledge the foregoing is true and accurate. <br />Name of Authorized Agent Signature Recei t Date <br />Section IV ASBESTOS - Generator/ Contractor <br />Contractor Name: Contractor Phone No.: <br />Special Handling Instructions and Additional Information: <br />Contractor Certification: I hereby declare that the contents of the consignment are fully and accurately described above by <br />proper shipping name and are classified, packed, marked, and labeled. Furthermore, in all aspects the material is in proper <br />condition for transport by highway according to applicable international and government regulations. <br />Contractor Name & Title: <br />Print/Type Contractor's Signature Date <br />Regulating Agency: Colorado Department of Public Health and the Environment, 4300 Cherry Creek Drive South, Denver, CO 80246-1530 (303) 642-2000 <br />Z (03/17) <br />