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I <br /> C 1,V? r <br /> - I• l •YY <br /> NON-HAZARDOUS <br /> : 25, 0.O <br />WASTE MANIFEST 3 81567 <br /> <br />1. Generator's Name and Complete Project Address <br />F oCKy ir'illllLri 113 Pipeline CAL"rpET131 <br /> <br />E. 1--25 Frontage 'Road Longmont, CO 30504 2. Bill to: <br />Rorjrcr' IIt L,' ipel itie <br /> .{G.3 2836-6402836-6400 1a. Generator's Phone 2a. Account # BR ? 6 <br /> r : J t,.?t rt ?+ 3. Transporter: Complete Company Name and Address 3a. Trarsporter's Phone <br /> ='` r? l%?<'v1 <'•? '? J/,ejf.;-;,'i1, f l.:•-:L1.,, ,'Lt1 J (<; s? Carp 'I' <br /> - 4. Transporter. Complete Company Name and Address 4a. Transporter's Phone <br /> Buffalo Ridge Landf i l 1 5. Designated Management Facility Name and Site Address 5a. Facility's Phone <br /> 1655 11(2. 59 ( 303 ) 732-0218 <br /> Heenesblarg, CO 80643 <br /> 6. Waste Code/Proflle # Waste Description Quantity Units <br /> 1007362 Unleaded Gasoline Conramianted Soil / <br /> J <br />G <br />E __ <br /> <br />N T <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 T 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 /> 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. Conlractor/Generator (` . <br />T Prlnted%0ed Full Name <br />) <br />? <br />? j' SignaturM(Full N e) Month Day Year <br /> <br />(• <br />R <br />A f I? (r it. <br />. <br />A E. ' L <br />--- '_ <br />N g. Transporter 1 Acknowledgement of Receipt of Materials <br />l <br />S <br />U ?? Printed/Typed Full Name <br />' l? j Si Oture (Full N ' ? h D Year <br />C3 <br />R ltA <br />.-?n1 ?. C1 Y1 .d%- <br />T <br />E 10. Transporter?.knowledgement of Receipt of Materials <br />R PrintedlTyped Full Name Signature (Full Name) Month Day Year <br /> 11. Discrepancy Indication Space 12. Ticket # <br />A Initials of Person noting discrepancy Dale _ <br />C I 13. Management Method/Location ? Solidification ? Monofill [Y Landfill ? Bio-Beds <br />L <br />I Grid Location (if applicable): <br />T <br />14. Facility Owner or Operator: Certilication of receipt of waste materials covered by this manifest except as noted in item 11. <br />y <br /> <br /> PrintedlTy I Full- e Signature (Full Name) j _---?' Month Day Year <br /> <br /> <br /> TRANSPORTER COPY <br />Hevrsion unn true