2007-11-20_REVISION - M1982015 ‎(18)‎

• Permit No: M1982015
• IBM Index Class Name: REVISION
• Doc Date: 11/20/2007
• Doc Name: Appendix 2, Rocky Mountain Pipeline Report ‎(March 2, 2007)‎
• From: E-21 Engineering, Inc.
• To: DRMS
• Type & Sequence: TR3
• Media Type: D
• Archive: No

ow
r!J ?, .
l
3
NON-HAZARDOUS

WASTE MANIFEST E c... 04b
W1.fT.MMIMYM?Nf-• r 381549

1. Generator's Name and Complete Project Address
i?riCi f' Ho'Jil%u i n P i *pe 1 i ne Cr,m1>al iy
' 210X?l E. -?? Frontage Rc)a LcnglTon'..; CO 80114

J
'
2.8illto: r
lc
tit n.r?:•1tr.e
'?
O

1a. Generator
s Phone
.x0 3 20b--6400
t
2a. Account N at
Y6 P
' t` •i '. '? j ?? ?,f' j rLu t'1 3. Transporter: Complete Company Name and Address 3a. Transporter's Phone
1J
i1 i- !` Y1 f t ? ? r? ? t.' r + ?„?, - F" `+? ? ?...: f .:; r• e-? f7 .+:''?? G-%Q .'
'? C.
4. Transporter: Complete Company Name and Address 4a. Transporters Phone ;

S'aifa to Ridge I.andf i l l 5. Designated Management Facility Name and Site Address 5a. Facility's Phone ?I

11-655 VICR 59
i.303)732-0218 i
Keenesburg, CO SE643
6. Waste Code/Profile it Waste Description Quantity Units
1-307362 Unleaded Gasoline Contamianted Soil

G
E
N
E

R
A
T NON-FRIABLE ASBESTOS WASTE ONLY (Friable may not be shipped on this manifest)
0
R Waste Code/Profile If Waste Description Quantity Yards or Drums

Nonfriable Asbestos
7. Regulatory Agency:
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
a. 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.
Be. Contractor/Generator A
T
A rmtedfNped Full Name
! FA N ?'1 ature Full Na e)J Month Day %ar
,
r
r
M1 i - _ / i
e ?a
N 9. Transporter 1 Acknowledgement of Receipt of Materials
S i
p 1 PrIntecirryped Full Name 'kJ SignBturpFylWame) Moon
t
r
h Day Ye
a
R .-._.J 1 t v, ?.•. ' --?C.J •t -- • ' r' ' ti '
?
?
/
r .. - _'-?' 13 CTJ ?'`i
T 10. Transporter 2 Ai kriowledgement of Receipt of Material
E
R Printedlryped Full Name Signature (Full Name) Month Day Year
11. Discrepancy Indication Space 12. Ticket N
A Initials of Person noting discrepancy Date S 9 fJ
13. Management Method/Location ? Solidification ? Monofill W Landfill ? Bio-Beds
L
I
T Grid Location (if applicable):
y 14. Facility Owner or Operator: Certification of receipt of waste materials covered by this manifest except as noted in item 11. r,
x
Printed/Typed FYI Name }
?? Si nature Full Name
g nature ) Month Day Year

C

TRANSPORTER COPY

Revision 04115102