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Non Hazardous Special Waste Manifest <br /> Waste Connections, Inc. Manifest: 1760 <br /> Section 1—Generator information (Must be filled out by the Generator) <br /> Approval Number: SSL- - 7 !' Expiration: <br /> i <br /> Generator Name: t�f_ ft r c,.;_;.^ L i„ ;,; Site Name: <br /> Address: x 1 i 4'. Address: .f. <br /> City, State Zip: i.o If 1 c"�1 /{ C City, State Zip: ,- i r t : C c`: c q r <br /> Generator Contact: ; �. ,', L , ;i Site Contact: <br /> Phone: 72 u- ''f `j Phone: <br /> Fax: .2 �, ( `'t Fax: <br /> Name of Waste `{"L- f 3` Bill To: <br /> Description of Waste: -I c,,,'; . C r; C. k. Address: <br /> City, State Zip: <br /> Disposal Volume: Yard(s) Ton(s) Phone: <br /> Other: Fax: <br /> I hereby warrant that the above material is the same material represented on the Special Waste Application identified by the above Special Waste <br /> Approval Code and such material was delivered to the transporter on the shipment date referenced below; <br /> /r^ <br /> .Gel rator s Auttorzed; hnt Name Hrit' Si'nature oFGenerator' Authoriz Agent .' ; Shipwt Date <br /> Section 2—Transporter Information (Must be filled out by the Transporter) <br /> Su <br /> Transporter Name: (~i Important Notice <br /> Address: 7 ; r: f C>1 ,, Disposal Facility below must be notified in <br /> �)3 � +�,-i tY <br /> City, State Zip: ;, ( ;? /�' o (,q ADVANCE before delivery of waste with <br /> Phoney ^/ } SL Cf G' ? ? SPECIAL HANDLING instructions <br /> Truck#: I T ` <br /> Thereby warrantt�iat the above material was picked up at the generator site listed above and delivered without incident to the destination listed <br /> t -.+ts✓)Aq't:F } `�'y 'slf a r r. fi,y.*^'.as <br /> �S' i' f ( Zx<�� i ✓ �3�:. J ) ��#1..!' ✓C ���If�L}.'f^ t�.�'7�$�rl'y�+.•k�' t�'4q n `��y J� f1x <br /> Tw�'`�' � ! .P i+ `,>� '` .di l„��^�[ .0 .! J"S.,.� Tz�W sX��,'�,r�-� "(,�y�•� �,��`""�-'� /J ,.-`YY /�Y <br /> 5 Name`of Driver�p la) „ . gnature of,C)tver k;„Date <br /> Section 3 — Destination Information (Must be filled out by the Disposal Facility) <br /> SOuthside Landfill Material Code: Account: Mix with Refuse ❑ <br /> 5715 Highway 78 West Volume Received: Yard(s) Ton(s) /- !A Other: <br /> Pueblo,CO 81005 Grid: Elevation: <br /> Phone: (719)948-2900 Safety Precautions: Avoid Skin&Eye Contact ❑ Avoid Breathing Dust ❑ <br /> V Fax: 719 566-6012 Ticket Number: <br /> ( ) Comments: <br /> �J�/�,�.r-+ 1'i',';i f'�f 1,�„pt1�,{.c, ;: . ... � ,.•:;^ :. J � � c ..-t.:^'.. ,.. <br /> Date.r. Landfill Authorized A ent Name int Si nature of Landfills''. Onzed Agent <br /> P <br /> White: Landfill Yellow: Generator Pink: Transporter Gold: Consultant <br />