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 Prolact Address
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„_ { : rt~ I y I'~, 1: l 2. Bill lo:
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1e. Generator's Phone
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2a. ACCOUnt# 1~ 1 t;i ~}1
3. Transporter: Complete Company Name and Address 3a. Tmnsporter's Phone
4. Transporter: Complete Company Name antl Address 4a. Transporter's Phone
S.i+ 7~i~i'•P::r: !:';'a~fj:i;'riIC SJi :'j.ICiSu ~ 5. fles(gnated Management Facility Name and Site Address Sa. r-acility's Phone
.;:'P;1\; _. )U i:it i;4 i?'i '.1 Lit"•)•'i G:id.Y. 4 /,j 4;j}n~f Fj-~';: io.:,ia

6. Waste Code/Profile # Waste Description Quantity Units
Au'rt!i:!.'.b S;~i. i jF\175ULU~3tiGE: e:ont w t'ayrtra;.t? 1:,
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NON-FRIABLE ASBESTOS WASTE ONLY (Friable may not be shipped on this manifest)

o -
R Waste Code/Profile a Waste Description Quantity Yards or Drums

Nonfriable Asbestos
7. Regulatory Agency:
Colorado Department of Public Health and Environment Emergency Notification: CHEMTREC [phone]
a3oo 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
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.
v 0a. Contractor/Generator
T .. - Prinied~Typed FulJ Name _: Signature (Full Name) ,n Month Oay Year

M g, Transporter 1 Acknowledgement of Receipt of Materials "-' '
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P , ~~ Printed/typed Full Name ~ Signature (Full Nang).; r - ri Month Day Year

T
E 10. Transporter 2 Acknbwletlgement of Receipt of Materials '
R PrinledRyped Full Name Signature (Full Name) Mo: th D:y Year
1 I. Discrepancy Intlicalion Space 12. Ticket #
F
A Initials of Person noting discrepancy Date
~ 1:3. Management Method/Location ^ Solidification ^ MOnofill ^ Landfill ^ Bio-Beds
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' Grid Location (if applicable):
7
`. 1.1. Facility Owner or Operator: Certification of receipt of waste materials covered by this manifest except as noted in item 11.
Prinled/Typetl Full Name Signature (Full Name) Month Day Year
Pr
? S' ~ CONTRACTOR'S COPY ~- IU ,
Revision 04/15/02