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T. <br />'57 rVV-1 -4 <br /> <br /> <br /> NON-HAZARDOUS <br />WASTE AAANIFEST °,n?,p„?1i25,•^_ <br />381 <br />55V; <br /> <br />r-or.;;y n ^t I'e ] ;n?e Gc3nt :an,l 1. Generator's Name and Complete Pro)ect Address _ <br />r <br /> _'?•vQ u, °25 "Frontage Rvac F t-ngmon't, CO 8C)5@ < <br />' 2. Bill to: o c1-y< I -It t i peI i ne <br /> la. Generator <br />s Phone <br />i03 2336-64:j0 <br />2a.Account# M ?b <br /> i • ^; ' ' ?.. _, / : 't - t .«. • 3. Transporter: Complete Company Name and Address 3a. Transporter's Phone <br /> r <br />,1 1 <br />!l';fG l i t• t-; Gt f :. t•, !t ?'i•;'f ?•_". '1 ' 1 r'r^. ; n L?,???-?,.>'? Y'Cr`"".q;:, !, <br /> <br />?t! .J .??'w1v •- '-''> j '` <br /> 4. Transporter: Complete Company Name and Address 4a. Transporter's Phone <br /> x <br /> Rut f a. I a ki ci3e Nandi 11 ? 5. Designated Management Facility Name and Site Address Sa. Facility's Phone j <br /> <br /> !1655 WLR 59 (303)732-0218 <br /> ??eerivsbtsrg, CO 30643 <br /> 6. Waste Code/Profile # Waste Description Ouanlity Units <br /> t <br /> 1007362 Unleaded Gasoline Contamiarted Soil <br />,f <br />~~ <br /> <br />G <br />E ?J <br />N <br />E <br />R <br />A <br />sf <br />T NON-FRIABLE ASBESTOS WASTE ONLY (Friable may not be shipped on this manifest) <br />O <br /> <br />R <br />Waste Code/Profile # <br />Waste Description <br />Quantity 73 <br />Yards or Drums t' <br /> <br /> - <br /> Nonfriable Asbestos w <br />7 <br /> <br /> <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 /> <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. ContractodGenerator <br />t <br />TR t mted/T ed Full Name 6Igr re (FgII Name) ) Month Day Year <br /> <br />S 9. Transporter 1 Acknowledgement of Receipt of Materials >< <br />U f ' PriQtedlTyped Full Name 41- 4 Signature (Full Name),- MV Day Yea+ <br />iy q <br />( <br />R J <br />gyp <br />T <br />E 10. Transporter 2 Acknowledgement of Receipt of Materials <br />R Printecirryped Full Name Signature (Full Name) Month Day Year <br /> 11. Discrepancy Indication Space 12. Ticket # <br />F <br />A <br />Initials of Person noting discrepancy Date <br /> 13. Management Method/Location ? Solidification ? MOnofill d Landfill ? Bio-Beds <br />L <br />I Grid Location (if applicable):" <br />T <br />y r' <br />14. Facility Owner or Operator: Certification of receipt of waste materials covered by this manifest except as noted in item 11. <br /> Printed(fyped Full Ame ?- 1 <br />? Signature (Eull N e) f ?r Month Day Ye r ? <br /> A t t• 7 .;;. <br />f ' C? ' ? V` ! Y.Y" ? r.'•rz%? ,??'%'f 1?i..r. "??? -G IJ t.' d? !? "1 <br /> <br /> =Y'fTRANSPORTER COPY . <br />' N } <br />1 <br /> z . <br />f <br />Revision 04115102