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

�7-/& � 171
VEW'Som
Non Hazardous Special Waste Manifest
Waste Connections., Inc. Manifest: N2 1759_
Section 1 —Generator Information (Must be filled out by the Generator)
Approval Number: SSL- 17 c Z Expiration:
Generator Name: Site Name: J,
Address: P.(" J` F I ('011 Address: �1 557 jt,. 0(111 w
City,State Zip: City, State Zip:
Generator Contact: rO Site Contact:
Phone: Phone:
Fax: -3t:)F - i 7 617 Fax:
4
Name of Waste N
LAA Bill To:
Description of Waste: +V11A 0,f- 1:1 C Address:
City, State Zip:
Disposal Volume: Yard(s) Ton(s) Phone:
� Other: Fax:
I hereby warrant that same e.-a:e above material is the mem6terialret)re�erit6donthe,SpecialWak�ApplicEiti�nidentified,i4�j ii�
v
-'materW;was delivei I 1 1 1—, .:: , —�:-!:-7
cl'to the transporter on the shipment date'referenced below
H
Generator's�Aathorized Agent Name(print)
Section 2—Transporter Information (Must be filled out by the Transporter)
Transporter Name: Alvr01--
Important NNotice-
-2
Address: 3?,5 ej Disposal Facility below must be notified in
City, State Zip: '1�410 ADVANCE before delivery of waste with
Phone: SPECIAL HANDLING instructions
Truck#:
Th f`eby<Watrdnt{that the above material was picked up at gen erator site listed above deliv6ni '%mih outiricideeit to the'degtl'
R. f7
NO
Se c tion 3— Destination Information (Must be filled out by the Disposal Facility)
-li Sou hside Landfill Material Code: 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:
J,
1-6ndfili'Authonzed Ag print)ant Si nature of:Landfill' 6thorized: e a
White: Landfill Yellow: Generator Pink: Transporter Gold; Consultant