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17 61 VEWso/ti 7f 5 <br /> Non Hazardous Special Waste Manifest <br /> lk A Waste Connections,, Inc. Manifest: N2 1759 <br /> Section 1 —Generator Information (Must be filled out by the Generator) <br /> Approval Number: SSL- 17 c Z, Expiration: <br /> Site Name: J, <br /> Generator Name: ./ -, , L,�e I r,�, <br /> -0-1c -C � , , , <br /> Address: Address: L! 5 5 7 <br /> tA , 0 <br /> C City,State Zip: City, State Zip: <br /> i-11c "Generator Contact: Site Contact: <br /> Phone: Phone: <br /> Fax: -312 ZIL 617 Fax: <br /> Name of Waste Bill To: <br /> Description of Waste: + 'J C Address: <br /> City, State Zip: <br /> Disposal Volume: Yard(s) Ton(s) <br /> Phone: <br /> rr Other: Fax: <br /> el material represented on the S pecial Waste Applic a ihe above, <br /> hereby warrant that;the above iaterial is the same bian identifed by, a maste <br /> Approval Code ive'r'e' 'refere;'irid�siJch-rraterial was�del' the transporter,on the shipment date'referenced below'.. <br /> d'to <br /> g":Nam (print) .Slgratpre^of Geherator4 Ag' <br /> Section 2—Transporter Information (Must be filled out by the Transporter) <br /> Transporter Name: A),Aa,r�01— Important Notice <br /> Address: <br /> Disposal Facility below must be notified in <br /> 04 <br /> City, State Zip: 1�,9 ADVANCE before delivery of waste with <br /> Phone: SPECIAL HANDLING instructions <br /> Truck #: <br /> j her`e6y"iyarrant that the above:ma_na,Fw; as,:picked`.* d ii <br /> lVered <br /> tevp'at the generator site listed above and e mit but inci ent <br /> below .. <br /> .......... <br /> I n re of Driver, Date . <br /> Section 3— Destination Information (Must be filled out by the Disposal Facility) <br /> S"u hside Landfill Material Code: Account: Mix with Refuse ❑ <br /> 5715 Highway 78 West Volume Received: Yard(s) Ton(s) Other: <br /> Pueblo,CO 81005 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 /> "mp -'SdaW <br /> i-ie�"'1 rjht)1 ': , '�"'i n re' .u <br /> White: Landfill Yellow: Generator Pink: Transporter Gold; Consultant <br />