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Sr z Jill <br />y <br /> <br /> NON-HAZARDOUS <br /> WASTE MANIFEST 2.225, 040 <br />3 8 ?. 5 5 5 <br /> f : r <br /> 1. Generator's Name and Complete Project Address <br /> Rcr clcy l lounta i n Pipeline Compal;y 2 <br />Bill to: <br /> <br />i2100 E. 1-25 Frontage Road Longmont, CO 80504 <br />l <br />G <br />t <br />' <br />Ph . <br />r <br />Rooky lit P i po 1 i ne <br />' <br /> enera <br />or <br />one <br />a. <br />s <br />303 486•-r 6400 2a. Account # <br />BR 96 <br /> ? k 1, rv? ?Yk.•! r ' 3. Transporter: Complete Company Name and Address 3a. Transporter's Phone <br /> p 2 r?/ L? /_;f t 1,}on ,:, .:r f7.-r1f r/'Sor1 ?-•c.'lor'?tdv v`G?'y(J `?iaJ .-l :s'-!Jt'cS.r <br /> 4. Transporter: Complete Company Name and Address 4a. Transportees Phone <br /> l <br /> 5. Designated Management Facility Name and Site Address <br />Bluffalo Ridge Landfill 5a. Facility's Phone ? <br />' <br /> 11655 14CR 59 (303)732-0218 } <br /> KeenesburcilCO 80643 <br /> 6. Waste Code/Profile # Waste Description Quantity Units <br /> 1007362 Unleaded Gasoline Contamianted Soil <br /> <br />G <br /> <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 # Waste Description Quantity Yards or Drums <br /> <br /> 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 />E: <br /> B. Contractor/Generator Certification: <br /> 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 /> 9a. Contractor/Generator <br />T rime yl d Full Name <br />J nature (F611 Name) 'I Month Day Year <br />R <br />A - <br />N 9• Transporter I Acknowledgement of Receipt of Materials <br />O intedlrypedfFull Name <br />A Signsia (Full Name)_ Month Day Year <br />R - <br />JirR t, <br />E 10. Transporter 2 A ledgemenl of Receipt of Materials <br />R Printed/Typed Full Name Signature (Full Name) Month Day Year <br /> 11. Discrepancy Indication Space 12. Ticket # <br />F 4 G1 (' <br />A Initials of Person noting discrepancy Dale <br /> 13. Management Method/Location ? Solidification ? Monofjll it Landfill ? Bio-Beds <br />L <br />I Grid Location (it applicable): <br />T <br />y <br />;4. Facility Owner or Operator: Certification of receipt of waste materials covered by this manifest except as noted in item 11. + <br /> Printedfryped .ffull Name Signature (,Full Name) • ? ' /?' Month Day Year <br /> <br /> <br /> r TRANSPORTER COPY <br /> Revision 0411510 <br />2 i