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NON-HAZARDOUS W 225 , 040 38055M <br />WASTE MANIFEST <br />riCC1cy i-i?unta in Pipeline Couipany 1. Generator's Name and Complete Project Address <br />Pipeline <br />121100 E. 1-25 F. c+r,f aGe Z:,ad Long iliont, CO 80509 2.aiuto: Rocky Mt <br />303 286-640,3 1a. Generator's Phone 2a. Account If ER 9a <br />.'f = r 3. Transporter: Complete Company Name and Address 3a. Transporter's Phone <br />4. Transporter: Complete Company Name and Address 4a. Transporter's Phone <br />aui f a i o R 1 r .??' i.an?f 1 1) 5. Designated Management Facility Name and Site Address 5a. Facility's Phone <br />(303)732-0218 <br />1105.5 ilCR 59 <br />KeenBsburg, CC 80643 <br />6. Waste Code/Profile # Waste Description Quantity Units <br />., n ea aso ne ContamianteCl 5011 <br />G v <br />E <br />N <br />E <br />R <br />A <br />T NON-FRIABLE ASBESTOS WASTE ONLY (Friable may not be shipped on this manifest) <br />0 <br />R Waste Code/Profile # Waste Description Quantity Yards or Drums <br />I <br />Nonfriable Asbestos <br /> 7. Regulatory Agency: <br />Emergency Notification: CHEMTREC (800) 424-9300 <br /> Colorado Department of Public Health and Environment 24 hr. toll free phone number <br /> 4300 Cherry Creek Drive South <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 materiafs.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 /> 8a. contractor/Generator <br />T Prjntedrfy0ad Full Name <br /> <br />nature (Full Na ' e) Month Day Year <br />Aft <br /> <br />A <br />N <br />9. Transporter 1 Acknowledgement of Receipt of Materials f <br />f <br />S <br />PP <br />tQdllyPad Full Name Month Day Year <br />SI natu a (Full N m U <br />j <br /> ?OG h IDS <br />?7 <br />R <br />T <br />10. Transporter 2 Acknowledgement of eceipt of Materials <br />R Printed/Typed Full Name Signature (Full Name) Month Day Year <br /> 11. Discrepancy Indication Space 12. Ticket <br />F f I rJ' / <br />A Initials of Person noting discrepancy Date <br />C 13. Management Method/Location El Solidification C3 Monofill Landfill ? Bio-beds <br />L <br />Grid Location (il applicable): <br />T <br />y 14. Facility Owner or Operator: Certification of receipt of waste materials covered by this manifest except as noted in item 11 <br />(Full <br />L. <br />Month Day Year <br />( • 71 ,'h <br />TRANSPORTER COPY <br />Revision 04115/02