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7 <br /> Non Hazardous Special Waste Manifest <br /> Waste Connections,, Inc. Manifest: N2 1762 <br /> Section I-Generator Information (Must be filled out by the Generator) <br /> Approxi,pi Number: SSL- Ekpiration: <br /> - 171- 2- 1 6., <br /> Generator Name: Site Name: <br /> rr-(�J C C/ <br /> Address: 77-Zoy- 11 Address: 4/ :55 7 <br /> City, State Zip: G 0 M-e 4 �10' City, State Zip: A(ktl,ct <br /> Generator Contact: G Contact: L% <br /> .k ,,Lvt �; A Site Conta <br /> Phone: 7 Z0 Phone: <br /> Fax: -3 v3 - (7-14? Fax: <br /> Name of Waste 0 C Bill To: <br /> Description of Waste: �a I'l VA r c c Address: <br /> City, State Zip: <br /> Disposal Volume: Yard(s) Ton(s) Phone: <br /> Other: Fax: <br /> PY represented.on the Special Waste Application identified by the above Specia Waste <br /> AppCaaC ocleandsuch kzlaterial was delivered to the transporter on the shipment a d f <br /> Z'D <br /> e � iedgent Name?( rent) <br /> "M <br /> Sign <br /> Section 2-Transporter Information (Must be filled out by the Transporter) <br /> Transporter Name: Important Notice <br /> Address: Disposal Facility below must be notified in <br /> City, State Zip: ADVANCE before delivery of waste with <br /> Phone: SPECIAL HANDLING Instructions <br /> Truck#-. 00 <br /> .a hetabove m�terEal was picked up at the generator site listed above and delivered Without inddent to the desftnation Ilstetl <br /> b" <br /> "a V <br /> ROOM, <br /> Section 3- Destination Information (Must be filled out by the Disposal Facility) <br /> -id'&hside Landfill Material Code: Account: Mix with Refuse El <br /> -5715 Highway 78 West Volume Received: Yard(s) Ton(s) Ti IVV Other: <br /> Pueblo,CO 11101 Grid: Elevation: <br /> Phone: (719)948-2900 Safety Precautions: Avoid Skin&Eye Contact ❑ Avoid Breathing Dust ❑ <br /> Fax: (719)566-6012 Comments: Ticket Number: <br /> MWO <br /> I W—UN—Am-- <br /> White: Landfill Yellow: Generator Pink: Transporter "Gold: Consultant <br />