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L--n/j Non Hazardous Special Waste Manifest Waste Connections, Inc. Manifest: • r 5 InformationSection I—Generator Approval Number: SSL-/7 - J d-j Expiration: /,)— 1 Generator Name: \ ._� ......-�-�, , �,.� Site Name: Address: _/ > �c \w Address: City, State Zip: y City, State Zip: Generator Contact: �Y,rev,: 1 ,, Site Contact: Phone: Phone: Fax: Fax: ti Name of Waste iBill To: Description of Waste: v2UGr, Address: City, State Zip: Disposal Volume: Yard(s) Ton(s) Phone: Other: Fax: i I hereby warrant that the above material is the same material represented on the Special Waste Application identified by the above Special Waste Approval Code and such material was delivered to the transporter on the shipment date referenced below. r 1 t, S e xti b`%S/C► L''(.,, _ C �:�ti ^�{ I Generator's Authorized Agent Name(print) Signature of Generator's Authorized Agent Shipment Date Section 2—Transporter Information (Must be filled out by the Transporter) Transporter Name: y �� r ,J, �� Important Notice Address: P7o y J Disposal Facility below must be notified in City, State Zip: P51,�-c e 11; - r'G 560)/JV/ ADVANCE before delivery of waste with Phone: �5i 76 - 75 IF- 36 SPECIAL HANDLING instructions Truck#: 4 T I hereby warrant that the above material was picked up at the generator site listed above and delivered without incident to the destination listed below. Name of Driver(print) Signature of Driver Date Section 3—Destination Information (Must be filled out by the Disposal Facility) Southside Landfill :Material Code: Account: Mix with Refuse ❑ 5715 Highway 78 West Volume Received: Yard(s) Ton(s) Other: Pueblo,CO 81005 Grid: Elevation: Phone: (719)948-2900 Safety Precautions: Avoid Skin&Eye Contact ❑ Avoid Breathing Dust ❑ S,`V Fax; (719)566 60i2 Comments: Ticket Number: �' Date Landfill Authorized A ent Name(print) Signature of Landfill's Aut rized Agent White: Landfill Yellow: Generator Pink: Transporter t Gold: Consultant