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<br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br />1 <br /> <br /> <br /> <br /> <br /> <br /> 3n :^ .. {.r .. ? r ?1 ., ao ca-tr?.?q? •'};,:fir <br /> <br /> <br /> NON <br />OUS <br />J LPIM <br />D <br />3815531 <br />0 <br /> 225,040 <br />WASTE MAN <br />E <br />ST <br />, <br /> Rocky 13csu.nta:li Pipeline c:arli,arnr 1. Generator's Name and Complete Project Address <br />f? <br /> I ? 2'' 00 2r . 1-25 Frontage R. ad Lcnyu?o:tt, CO 80504 z.8nlto: Rocky !it 'Pipeline <br />a <br />1 y + 03 286-64'x% 1a. Generator's Phone 2a. Account # BR 9t <br /> <br />i 3. Transporter: Complete Company Name and Address <br />: ;•, . , - % ;/ ,. t.; ?? 3a. Transporter's Phone <br /> ` <br />n <br />/r ?.l i=l??c,7 rra, ?1•"-n, fit":c?7 Gf,fvr L4L,,G.•'G<?2; <br /> 4. Transporter: Complete Company Name and Address 4a•Transporter's Phone <br /> <br /> BurLfaio Ridge Landfill 5. Designated Management Facility Name and Site Address 5a. Facility's Phone # <br /> 116 VCR 59 ( 31213) 732-0215 <br /> Keenesburg, CO 80643 ' <br /> <br /> 6. Waste Code/Profile # Waste Description Quantity Units <br /> <br /> 1007362 Unleaded Gasoline Contamianted Sail r <br /> <br /> G <br /> E <br /> <br /> N <br />R { <br />S <br /> <br /> A <br />T <br />NON-FRIABLE ASBESTOS WASTE ONLY (Friable may not be shipped on this manifest) <br /> 0 <br /> <br /> R Waste Code/Profile # Waste Description Quantity Yards or Drums ?r+ <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, Cd 80222-1530 <br /> 8. Conlractor/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. i' <br />u <br /> Be. Contractor/Generator <br />n <br /> T Print edlT' Lid Full Name <br />A ?6agnature (Full Name) _ Month Day Year <br />r <br /> A (' ?? r 11 <br />AI rY1 E if 1_--_ .?? l C <br />• <br /> N 9, Transporter 1 Acknowledgement of Receipt of Materials <br /> <br />S } <br />- <br /> <br />0 <br />(t?r?rttedCryp?i FullName <br />1 v L / h <br />I 1 1 ? <br />l j ' a u- (Full jda Month Day Year <br />qna <br />am <br />" <br /> R _ <br />, <br />s /1 c <br />; .- - Y? ? r. <br />• ? c <br /> E 10. Transporter 2 Acknowledgement of Rec ipt of Materials <br /> R Printed/Typed Full Name Signature (Full Name) Month Day Year <br />• • • Ai <br /> 11. Discrepancy Indication Space 12. Ticket # <br />e <br /> F / <br /> A Initials of Person noting discrepancy Date <br /> C <br />I <br />L <br />13. Management Method/Location ? Solidification ? Monoffll Landfill ? Bio-Beds jr <br /> l Grid Location (if 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 /> ed Full Name Si <br />Prinled/T <br />nature (Full Name) M <br />th D <br />Y <br /> yp <br />g <br />on <br />ay <br />ear r <br /> <br /> T <br />O <br />w <br /> RANSPORTER C <br />PY <br />l <br /> ? ? <br />i?dp <br />Revision 04/15102