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f <br /> NON-DOUS <br />A <br />381547 <br /> WAS E <br />0,40 <br />MAN PEST <br />otrenn ?•?• J <br /> 1. Generators Name and Complete Project Address <br />1 <br />li 1 1.-', , , Ce <br />r:::.)' r.C31;? i? . j!z 1 1 112 tti;:Arly <br /> <br />X100 =-. i-Gt ii'Ci1 c? t? F:Jc•, !.LrJtgr4-canz, CO 3CD504 2. Hill to: <br />Rozliy "1t 'Pipe.11ne <br /> 1a. Generators Phone 2a. Account # E),R 91i <br /> rr' 3. Transporter: Complete Company Name and Address 3a. Transporter's Phone <br /> <br /> 4. Transporter: Complete Company Name and Address 4a. Transporter's Phone <br />f <br />, <br /> , 5. Designated Management Facility Name and Site Address <br />Bu?',. F a1in _??..c_ica L'ardil s 1 5a. Facility's Phone r <br /> 11655 61CR 59 (303) '; 32•-0213 <br /> KeeneslyLug, CO 30643 <br /> 6. Waste Code/Profile # Waste Description Quantity Units <br /> 1007362 Unleaded Casollne Contamlanted Sall <br />G <br />E <br /> <br />N <br />E <br />R <br />A <br />T <br />NON-FRIABLE ASBESTOS WASTE ONLY (Friable may not be shipped on this manifest) <br /> <br />0 <br />R Waste Code/Profile # Waste Description Quantity T Yards or Drums <br /> <br /> Nonfriable Asbestos <br /> 7. Regulatory Agency: <br /> Colorado Department of Public Health and Environment Emergency Notification: CHEMTREC (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 /> Be. Contractor/Generator <br />T P(inted/T ped Full Name <br />I i-Signalur4i (Full N } Month Day Year <br />? <br /> Ill-A I., L <br />A - <br />N <br />S 9. Transporter 1 Acknowledgement of Receipt of Materials <br />P C ; Printed/T d Full Name <br />l r Ypg I Signa fa.(Vull Name) Month Day year <br />c <br /> <br />T <br />E 10. Transporter 2 Acknowledgement of Receipt of Materials <br />R Printed/ryped Full Name Signature (Full Name) Month Day Year <br /> 11. Discrepancy Indication Space 12. Ticket # <br /> 3 U3 '/ r? v <br />A Inilials of Person noting discrepancy Date <br />c1 13. Management Method/Location ? Solidification ? Monofill Landfill ? Bio-Beds <br />L <br />I Grid Location (i1 applicable): <br />T <br />Y <br />14. Facility Owner or Operator: Certification of receipt of waste materials covered by this manifest except as noted in item 11. <br /> Printedrryped Full me Signature (Full Na Month Day Year <br /> <br /> <br /> CONTRACTOR'S COPY <br />Revision 04/15102