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<br /> M -1, <br />r <br />t <br /> t <br /> NON-HAZARDOUS <br /> r 040 381559 <br />w?sn tnwwwa.ruvr" c. , <br /> 1. Generator's Name and Complete Project Address <br />Rock, I'f ct it a i t', P i I-° ! a rte Company <br />,„ <br /> <br />12 1??l E. %•-%r, _rant:a,:re Road I,ongimont, CO 3O504 <br />' 2.8ii1 to: <br />Rocky 'It. Pipeline <br /> 1a. Generator <br />s Phone <br />403 286--E40(13 <br />2a. Accouni g PR 316 <br /> <br /> 1: ; ?• ,..}'...w.ilrt.c:.? .' 3. Transporter: Complete Company Name and Address 3a. Transporters Phone <br /> r o i ar /?' < 7? =" _ ; <br /> ' 4. Transporter: Complete Company Name and Address 4a. Transporter's Phone C <br /> <br />5. Designated Management Facility Name and Site Address <br />i3t2S f?;O Ridge Lanai 111 <br />Sa. Facility's Phone <br /> 11655 11CP 59 ( 3,33) 7 32 -0218 p <br /> Keenesl}UY , CO 80643 I3 <br /> 6. Waste Code/Profile # Waste Description Quantity Units <br />t; <br /> 10407362 Unleaded Gasoline Contamianted Soil A?,' <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 /> <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 Emergency Notification: CHEMTREC (800) 424-9300 <br /> 4300 Cherry Creek Drive South 24 hr. toll free phone number <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 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 /> Be. Co ntractoriGenerator <br />r"1 <br />T l lPrinted%kd Full Name ASignaturb (Full N Month Day Year <br /> <br />N 9. Transporter 1 Acknowledgement of Receipt of Materials <br />S <br />P <br />R ? Printed/Typed Full Naha <br />T-0 A, C_ ' M. (Full Name) Month /Day Year <br />T <br />E 10. Transporter 2 Acknowledgement of Receipt of Materials 1 <br />R Printedrryped Full Name Signature (Full Name) Month Day Year <br /> 11. Discrepancy Indication Space 12. Ticket It <br />F <br />A <br />Initials of Person noting discrepancy Date <br />/ rr <br />c 13. Management Method/Location D Solidification ? Monofill [i Landfill ? Bio-Beds <br />L <br />I <br />T Grid Location (if applicable): <br />Y 14. Facility Owner or Operator: Certification of receipt of waste materials covered by this manifest except as noted in item 11. <br /> -r <br /> Printed/Typed Full Name _,?--•- - -- ?_ Signature (Full Name)) <br />,.," Month Day Year <br /> / <br /> <br /> TRANSPORTER COPY ; <br /> <br />KeVISton 04115,U2