GENERAL30221

• Permit No: M1978052
• IBM Index Class Name: General Documents
• Doc Date: 5/26/2004
• Doc Name: Reportable Spill Test Results
• From: Lafarge West Inc.
• To: DMG
• Media Type: D
• Archive: No

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~ - NON-HAZARDOUS

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WASTE MANIFEST
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~+ 1. Generator's Name and Complete Project Address
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; 2. Bill lo:
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1a. Generator's Phone 2a. Account # ; "-~

I 3. Transporter: Complete Company Name and Address 3a. Transporters Phone
4. Transporter: Complete Company Name and Address 4a. Transporter's Phone
_, ,5. Designated Management Facility Name and Site Address 5a. Facility's Phone

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6. Waste Code/Profile # Waste Description Quantity Units
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NON-FRIABLE ASBESTOS WASTE ONLY (Friable may not be shipped on this manifest)
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I.l Waste Code/Profile # Waste Description Quantity Yards or Drums

I Nonfriable Asbestos
7. Regulatory Agency:

I Colorado Department of Public Health and Environment Emergency Notification: CHEMTREC [phone]
4300 Cherry Creek Drive South 24 hr. toll free phone number
Denver, CO 80222-1530
8. Contractor/Generator Certification:
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
I quantities of PCB's or radioactive materials. This waste has been accurately classified, described, packaged, marked and labeled and is in proper
condition for transportation according to applicable international and governmental regulations.
tl 0a. Contractor/Generator
1' ~ / Prinledliyped Full Name .Signature (Full Narne) r Month Day Year;

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PI 9. Transporter 1 Acknowledgement of Receipt of Materials t
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O ~ / Printed/typed Full Name ~Signalure (Full Nam
e) ..~' Month Day Year
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~ 10. Transporter 2 Acknowledgement of Receipt of Materials '
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FI Printed/Typed Full Name Signature (Full Name) Month Day Year
1 11. Discrepancy Indication Space 12. Ticket #
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A Initials of Person noting discrepancy Date
13. Management Method/Location ^ SOidiflCatlOn ^ MDnofill ^ Landfill ^ Bio-Beds
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I Grid'Location (if applicable):
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14. Facility Owner or Operator: Certification of receipt of waste materials covered by this manifest except as noted in item 11.
Prinled(ryped Full Name Signature (Full Name) Mo: th Day Year
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a' _ /*':~ t.~ 4 >s ,'~ = CONTRACTOR'S COPY ., nT ~ ~- ;. -
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Revleton 04/15/02