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<br />~ NON-HAZARDOUS <br />~ ;~'] r~ + '"? <br />~ ~ <br />/' <br />` <br />~ <br /> <br />,•~. 4'i ~.+' <br />WASTE MANIFEST • <br />•^' <br />-• ~ <br />• <br /> 1. Generator's Name and Complete Project Atltlress - - . <br />t,' <br />~~ 'r+~ <br />i <br />`r : <br />1~' ' <br />' <br /> .,a$.2.~i,e 4iair::~. aru• <br />., ._ <br />, <br />. <br />. <br />S_ <br />,.. .. <br />2. Bill to: <br /> 4 ,,•)ef <br />i~ 1 _~1 .lr, r' ~ ~ ~ r, a ->; ~ <br />sn ; \. 1 ~'ii!`~ ~ i-'•~^f,1.:.Y-~- <br />' <br />- ,,ra:%,.;:;)~r 'rle~" <br /> 1a. Generator <br />s Phone <br />1 ~~' 2a. Account q <br /> 3. Transporter: Complete Company Name antl Address 3a. Transporter's Phone <br /> l )/r <br />) <br />' 'r~i !i 1ji <br />/ ~ <br />' %%. <br />i 1` 'il _~, f <br /> te <br />r <br />. <br />, <br />(, <br /> 4. Transporter: Complete Company Name and Atldress 4a. Transporters Phone <br /> . 5. gesignated Management Facility Name and Site Address <br />" <br />' <br />'i <br />i <br />' <br />' Sa. Facility's Phone <br /> s"?2i1. <br />4~X <br />.r <br />i!'n iii°i <br />;n':iU`,::1 ~. .~3 ,... <br />IG(~ <br />' <br /> F2.fj(iJ <br />'i 4'~Q~ _S~GCI'e,)1, ., _.,, ~.,: !.I~1 I, 34`i j~`.i~l'G"a[•,.'',!1 <br /> <br /> F. Waste Code/Profile # Waste Description Quantity Units <br /> i':9r!)5i ~~) ;301 iirr+,3 i$C.1'1:iE?~ir.:5 CiS?S'!Y. Sd%}]y dYui~Ll ~)'tC <br />G <br />E <br /> <br />N <br />E <br />R <br />A <br />T NON-FRIABLE ASBESTOS WASTE ONLY (Friable may not be shipped on this manifest) <br />0 <br /> <br />R Waste Code/Profile # Waste Description Quantity Yards or Drums <br /> <br /> Noniriable Asbestos <br /> 7. Regulatory Agency: <br /> Colorado Department of Public Health and Environment Emergency Notification: CHEMTAEC (800) 424-9300 <br /> 4300 Cherry Creek Drive South 24 hr. toll free phone number <br /> Denver, CO 80222-1530 <br /> 8. Contractor/Generator Certification: <br /> I hereby certify that the above described waste is not a hazardous waste as defined by federal, state or local regulations and does not contain regulated <br /> quantities of PCB's or radioactive materials. This waste has been accurately classified, described, packaged, marked and labeled and is in proper <br /> condition for transportation according to applicable international and governmental regulations. <br /> IIa. ConUaclorlGenerator <br />T _ Printed/Typep Full Name Signature (Full Natpe) _, % ~% Month Day Year <br /> <br />M 9~Transporter 1 Acknowlodgement of eceipt of Materials ..T j <br />S <br />P Printedlfyped Full Name `~ SignatureJ(Fuil_Name) <br />/ Mo <br />n~h Day Year <br /> l <br />~4 <br /> <br />T 10. Transporter 2 Acknowledgement of Receipt of Materials <br />F: <br />R Printed/Typed Full Name Signature (Full Name) " "~- ~"-"~' ~ • Month Day Year <br /> 11. Discrepancy Indication Space 12. Ticket h <br />F <br />A Initials of Person noting discrepancy Date <br /> <br />t. 13.MariagemenlMethod/Location ^ Solidification ^ Monofill ^ Landfill ^ Bio-Beds <br />I <br />5" Grid Location (if applicahle): <br />y 14. Facility Owner or Operator: Certification of receipt of waste materials covered by this manifest except as noted in item 11. <br /> PrintetllTypetl Full Name Signature (Putt Namej Month Day <br />Year <br /> (I <br />-L <br />v <br />r ,~.T"rA"~+ r <br />~' ~~~"~)~~~* &; ~ _ CONTRACTOR'S COPY ~")'-,, _ _ <br />Revision 04!15/C <br />