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 760
Section I—Generator Information (Must • - filled out by the Generator)
Approval Number: SSL- - !' i Expiration:
Generator Name: r�,.;_;.^ i Site Name:
C !: ��:� ; �, r
Address: '�; x i `I �i t1 Address
City, State Zip: I,c� #, i f"�1 ; City, State Zip: ;-1 1
Generator Contact: `��; ` , ., r,f-�;;; Site Contact: ! • c' 1
Phone: 72 o, 'r f `` F Phone:
Fax: ,L 2, - r° (7 - Fax:
1 ,
Name of Waste `{�IA1 \1 U;;> r Bill To:
Description of Waste: -! c,t,;.� ( U C. Address:
City, State Zip:
Disposal Volume: Yard(s) Ton(s) Phone:
Other: Fax:
Ishereby warrant that a!the above material is the same material represented on the'Spea 1Naste Application identified by the above Special Waste
�Approva!Code and such maberlal was delivered to the transporter on the shipment date referenced below.
M 1 �11
irvn' '" ` .,h'+1` iL„ 1G?EC ...i, 3 '`- • ttiw "'rd'� t C�
.r-r +^'•
'Mr
agent Name(Rnrit) Signature of Generator AuthorizAgen +�,d,,;Stlipert Date
Section1 • • • • - - • • bythe Transporter)
Transporter Name: Important Notice
Address: K'-i Disposal Facility below must be notified in
City, State Zip: ADVANCE before delivery of waste with
Phone: n� c [r = G' ? ? SPECIAL HANDLING instructions
Truck #: k I T -
I}iereby w, . ,"
a�ran�" `atttie"above material was picked up at the generator site listed above and delivered without incident,to'the destination listed`
BtTle OfgYEprlflt) SlgrZature of Dreier: DaYe''r
Section 3 — Destination Information (Must be filled out by the Disposal Facility)
Southside landfill Material Code: Account: Mix with Refuse ❑
5715 Highway 78 West Volume Received: Yard(s) Ton(s) ,P Other:
Pueblo,CO 81005 Grid: Elevation:
Phone: [phone] Safety Precautions: Avoid Skin&Eye Contact ❑ Avoid Breathing Dust ❑
Fax: [phone] Comments: Ticket Number:
h..
Date, "rY lari8fill.Authoilzed l 'erit`Name Tint SI-nature of Landfill's A honied Agent,
White: Landfill Yellow: Generator Pink: Transporter Gold: Consultant