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Jill <br />- - <br />!!! <br />'r <br /> NON-HAZARDOUS J •i25,040 <br />I ? f1 <br />80550. <br /> WASTE MANIFEST 3 <br /> ?C l y 1.1c.-Lint a i P. 4 i pe : i ne Cw pant' 1 • Generator's Name and Complete Project Address <br /> 12100 E. I-?5 `'r.ontage Road 1,ingptowt., CO 8x,504 2.8011o: Roozky Ht Pipeline. <br /> 3(33 2213- 6400 1a. Generator's Phone 2a.Account# BR 96 <br /> nn <br />Can ' 3. Transporter: Complete Company Name and Address 3a. Transporter's Phone <br /> 'r r' •+?. _i ?Gt/i<?G? ?t%_i - ?CJ'7 U'?i? <br /> 4. Transporter: Compete Company Name and Address 4a. Transporter's Phone <br /> Burl a 1 o R i dC? @ Lai iC' } ] 1 1 5. Designated Management Facility Name and Site Address 5a. Facility's Phone <br /> ..1.5_`5 i/CP 5? 13 0 317 i:' 23: 18 <br /> :?eenusar rrq , cCQ 84)643 <br /> 6. Waste Code/Profile # Waste Description Quantity Units <br /> 1007362 Unleaded Gasoline ,on amian-to <br /> ? r <br />G <br />E <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 />0 <br />R Waste Code/Profile k Waste Description Quantity Yards or Drums <br /> <br /> 7 Nonfriable Asbestos <br /> 7. Regulatory Agency: <br />Colorado Department of Public Health and Environment <br />Emergency Notification: CHEMTREC (800) 424-9300 <br /> 4300 Cherry Creek Drive South 24 hr. toll free phone number <br /> Denver, CO 80222-1530 <br />d <br /> <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 /> ea. Contractor/Generator <br />T P?inted/Typ d Full Name Signature (Out] Na e)} Month Day Year <br /> <br />N 9. Transporter 1 Acknowledgement of Receipt of Materials <br />5 <br />P <br />j PrincyTyped full Name <br />, li Signature (Full Name) r; )?i fin Month D"ay Year <br />R -ti <br />T 10. Transporter 2 Acknowledgement of R • eipt of Materials <br />E <br />R <br />Printed/Typed Full Name Signature (Full Name) Month Day Year 7 <br /> <br /> 11. Discrepancy Indication Space 12. Ticket 4 <br />A Initials of Person noting discrepancy Date / Y7 <br />1 13. Management Method/Location ? Solidification ? Monofill Cif Landfill ? Bio-Beds <br />L <br />I Grid Location (if applicable): <br />T <br />14. Facility Owner or Operator: Certification of receipt of waste materials covered by this manifest except as noted in item 11. a <br />Y <br /> Printed/Typed Lull Nayw j '` / Signature (Full Name) •...... Month Day/ Year <br /> <br /> <br /> <br /> TRANSPORTER COPY <br /> <br /> <br />Revision 04115102