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NON-HAZARDOUS 040 <br />WIM225 3 8 0 5 7 2 <br />WASTE MANIFEST , <br />SGCky )'fountain Pipeline Corrapany 1. Generaloes Name and Complete Project Address <br />3.2113.3 E. 1-25 Frontage Road Longmont, CO a05O4 2• sill to: Pocky Mt Pipeline <br />333 286-6400 Ia. Generator's Phone 2a. Account 11 P,R 96 <br />i ; .+? <c? 3. Transporter: Complete Company Name and Address 3a. Transporter's Phone <br /> <br /> 4.Tran porter: Complete Company Name and Address 4a.Transporlees Phone <br /> <br />Buf is lo R i doe La df i i 1 5. Designated Management Facility Name and Site Address 5a. Facility's Phone <br />1655 I CR 59 ( 303) 73.?.--9218 <br />Keenesburg, CO 8Oi;43 <br />i <br />6. Waste Code/Profile # Waste Description Quantity Units <br />G <br />E <br />N <br />E <br />R <br />A <br />T <br />O <br />R <br />NON-FRIABLE ASBESTOS WASTE ONLY (Friable may not be shipped on this manifest) <br />Waste Code/Profile # Waste Description Quantity Yards or Drums <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 />8a. Contractor/Generator <br />T Printefvtyped Full Name t 1,41griature Full Na ) Month Day Year <br />A M v_ <br />N <br />S 9. Transporter 1 Acknowledgement of Receipt of Materials <br />P `` Printed/Typed Full Name l Signatu ull amtfj'? ?? "'' Month Day Year <br />E 10. Transporter 2 Ack ,ledgement of Receiplpf Materials ff` <br />T <br />R Printed(Typed Full Name Signature (Full Name) Month Day Year <br />- <br />11. Discrepancy Indication Space 12. Ticket If <br />F <br />A Initials of Person noting discrepancy Date _ <br />13. Management Method/! ovation ? Solidification ? Monofill Landfill ? Bio-Beds <br />L <br />I Grid Location (if applicable): <br />T <br />Y 74. Facility Owner or Operator. Certification of receipt of waste malerials covered by this manifest except as noted in item 11. } <br />EHc <br />Signature (Full <br /> <br />Month Day Year <br />? -Zlr•' ?Ir':' <br />COPY <br />Revision 04/15102