2020-01-29_REVISION - M2017003

• Permit No: M2017003
• IBM Index Class Name: REVISION
• Doc Date: 1/29/2020
• Doc Name: Request for Technical Revision
• From: Colorado Calumet Co., Inc.
• To: DRMS
• Type & Sequence: TR4
• Email Name: ERR
• Email Name: MAC
• Email Name: AWA
• Media Type: D
• Archive: No

CW .
Non Hazardous Special Waste Manifest
r
j Waste Connections, Inc. Manifest:
Approval Number: SSL- - ) `? i Expiration: -) U
Generator Name: �_ ;�uv -U f��� Site Name: -
Address: *%` �� �. Address: 5 -7 (j
City, State Zip: C E_ trn-, t� ' ` City, State Zip:
Generator Contact, Site Contact: -
Phone: Phone:
Fax: ( 7.7 7 (0 3 Fax:
Name of Waste JN��r.t 7�c Bill To:
Description of Waste: -+—r^-e `¢?oC,k Address:
City, State Zip:
Disposal Volume: Yard(s) Ton(s) Phone:
Other: Fax:
.k hdi warrant that the above material is the same material represented on the Special Waste Application identified by the above,Speci4 Wa to
Appro�fal:CAde and such material was delivered to the transporter on the shipment date referenced below.
ES
51 f i '. s. 3 S 11, (1 1-ci 1.'14191.o ♦ b r ' ::l - J r y- y ,,£7
'� r'�s�o$r(��ed�fgen�JVame,(print) xS gi rr�ature of Generator Audto�rt�d t g hYfi.���"- Ship" nt Dat ' f n��;�y�,�:3 � �' .
Section 2—Transporter Information (Must be filled out by the Transporter)
€.. t-. �x>., r r..•c.,. ...a.rt.Nr.-. r ,>E:�3s ttr R,..,
Transporter Name: A J�eA, -' L t Important Notice
Address: 3 5 ) T3 _���f :5 Disposal Facility below must be notified in
� I
City, State Zip: r ^/D 2 /72 ADVANCE before delivery of waste with
Phone: ) % d-I/V 3 ,z SPECIAL HANDLING instructions
Truck.#: / 3 z -
'flereby Iarrantft at the above matenal was picked up at the:generatorslte'listed above and delN&W wIt}mutj1nGdent to the clop adon li W'I
•r h ���ys ���4 �- ,/ � t t-,r- t ' � tt-.�' rt.�..✓�a� '?-��,���x 1"``z
.7 �r.� d a _Ne�t
rss^j, o �.Yas,
�te ff xj� ; WON,,
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Destination
. -
• be . . Disposal
Sb thside Landfill MaterialCode: Account: Mix with Refuse ❑
5715 Highway 78 West Volume Received: Yard(s) Ton(s) j� c'0 D' Other:
r Pueblo,CO 81005 Grid: Elevation:
Phone: [phone] Safety Precautions: Avoid Skin&Eye Contact ❑ Avoid Breathing Dust ❑
Fax: [phone] Comments: Ticket Number:
Date: LandfDf-Authorii,Me4 Name(Orin ire of Landfill', `' horized A ent
White: Landfill Yellow: Generator Pink: Transporter Gold: Consultant