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Non Hazardous Special Waste Manifest <br /> Waste Connections, Inc. Manifest: N_ ± � <br /> SectionGenerator) <br /> Approval Number: SSL- - 1702 1 Expiration: <br /> Generator Name: f()(�,o Site Name: ro;. V). <br /> Address: .0. t5pX Address: S r ed <br /> City, State Zip: oZ. City, State Zip: mma <br /> Generator Contact: am- Ot,,/ �U+ e Site Contact: <br /> Phone: I Z©~ 3 l 3✓ Phone: <br /> Fax: '�03- 7������ Fax: <br /> Name of Waste I'OC K Bill To: <br /> Description of Waste: �-u+,� ,�� Cfl CGK Address: <br /> City, State Zip: <br /> Disposal Volume: Yard(s) Ton(s) Phone: <br /> Other: Fax: <br /> x herefayv arCant that the above material is the same material representW.on the Special Waste'Application identified by the,above.5peaal Waste <br /> Ap rdva :odey�nd••such materla1 Was-delivered to the:transporter o6 the shipment date referenced below. <br /> ` tie sAOEhotjzedl eht Name(print} ..., Slgr?ature oF,Gggerator's AuthoXized.Agent, Shipment Date; <br /> Section 2—Transporter Information (Must be filled out by the Transporter) <br /> Transporter Name: L'+a(jawztr fst�,{ Important Notice <br /> Address: 3 6 t Disposal Facility below must be notified in <br /> City, State Zip: ad to ADVANCE before delivery of waste with <br /> Phone: f �� 7 SPECIAL HANDLING instructions <br /> Truck #: <br /> I"} Iehy+Havant that he above material was picked ap at the,generator site-listed above and delivered without'incident to,the�est�nation listed <br /> be7t5W ., <br /> t, _ t <br /> 077.­ <br /> tame u Erier�(pr�rit SigriattTre of Driver Date <br /> Section .�Destination' Informationbe filled rout I the Disposal <br /> Southside Landfill Material Code: Account: Mix with Refuse ❑ <br /> 5715 Highway 78 West Volume Received: Yard(s) Ton(s) ,f 3 a Other: <br /> Pueblo,CO 81005 Grid: Elevption: <br /> Phone: (719)948-2900 Safety Precautions: Avoid Skin&Eye Contact ❑ Avoid Breathing Dust ❑ <br /> Fax: (719)566-6012 Comments: Ticket Number: �-Br�f to <br />