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Non Hazardous Special Waste Manifest <br /> r� <br /> Waste Connections, Inc. Manifest: N- 1 ^ <br /> • - . out • <br /> Approval Number: SSL- - 17024, Expiration: <br /> Generator Name: j�Cir�o If n 6� Site Name: bz+r04 V4- <br /> Address: .0, px L t tog Address: S r k <br /> City, State Zip: C: <br /> XcjAf,0 W, 60LOZ, City, State Zip: MCL <br /> , <br /> Generator Contact: G���,,t ,� L�� Site Contact: rnn �Lr iA <br /> Phone: 7 zo- 3 i 9 " e cl 33 Phone: <br /> Fax: 30- ?-78- 2U 3 Fax: <br /> Name of Waste �L"V�V1 e ( f-0CK Bill To: <br /> Description of Waste: u rai�VA e- j CJ(-K Address: <br /> City, State Zip: <br /> Disposal Volume: Yard(s) Ton(s) Phone: <br /> Other: Fax: <br /> I hereiay 4 rarttthat, gabove rn tb?Aal,ii:iM same material represented.on the Special Waste'Application identified by the Special Waste. <br /> Ap X��a> odey nd such material'was del'fvered to the-transporter on:,a shipment date referenced below. <br /> i FieE,atq's ft� ior�zed�1 ept l�[amegprint): Sjgnature;of Ggnerator's Authorized Agent. Shipment Date: <br /> 1—Section 2—Transporter Information (Must be filled out by the Transporter) <br /> Transporter Name: e-v&- ie Important Notice <br /> Address: 63 Disposal Facility below must be notified in <br /> City, State Zip: ✓ f Ca 416, ADVANCE before delivery of waste with <br /> Phone: r Z(C) SPECIAL HANDLING instructions <br /> Truck#: 6C4 31Y <br /> 7 h l eby iHar ant that the above material was pllz ed up at the,-' rator Bite-listedabove and delivered withoutincident-tothe desbriaGor I�steii <br /> beiaw <br /> op <br /> „> ? labPlnery(pnnt 5ignatureof:Delve[ Date <br /> Southside Landfill Material Code: Account: Mix with Refuse ❑ <br /> 5715 Highway 78 West Volume Received: Yard(s) Ton(s) �;;i,f. 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: )-f�f ju <br />