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

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Non Hazardous Special Waste Manifest
Waste Connections, Inc. Manifest: N K.
Section I-Generator Information (Must be filled out by the Generator)
Approval Number: SSL-/? - c7,-j-j Expiration: �- 1
Generator Name: Site Name:
Address: Address: L/ 5 tit c
City, State Zip: City, State Zip: % � ✓ c"✓�j 2 i
Generator Contact: /r ��,` � �S G v- Site Contact:
Phone: ;, ;a 5 `5 %5{ ', Phone:
- a
Fax: Fax:
Name of Waste Bill To:
Description of Waste: vtt cr-- Address:
City, State Zip:
Disposal Volume: Yard(s) Ton(s) Phone:
Other: Fax:
}
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.
Generator's Authorized Agent Name(print) Signature of Generator's Authorized Agent Shipment Date
Transporter . . be filled out by the Transporter)
Transporter Name: ,':� 1 h/ J 1« Important Notice
Address: P7ov 7, & 2 J Disposal Facility below must be notified in
City, State Zip: /15f N c• - r 5U J I/ ADVANCE before delivery of waste with
Phone: 70 - 3 5 SPECIAL HANDLING instructions
Truck#: 7-,!
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. p
�
Name of Driver(print) Signature of Driver Date
Section 3—Destination Information (Must be filled out by the Disposal Facility)
Southside Landfill :Material Cade: Account: Mix with Refuse ❑
5715 Highway 78 West Volume Received: Yard(s) Ton(s) Other:
Pueblo,CO 81005 Grid: Elevation:
Phone: [phone] Safety Precautions: Avoid Skin&Eye Contact ❑ Avoid Breathing Dust ❑
._ Fax: [phone] Comments: Ticket Number:
Date Landfill Authorized A ent Name(print) Signature of Landfill's ZttXrized Agent
White: Landfill Yellow: Generator Pink: Transporter Gold: Consultant