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NW-18-8010 15::30 From: <br />To:303 Pate:4-7 <br />MANIFEST REQUEST FORM <br />Please a mplotc this foam in order to assist us in propwiog your monifost order! <br />Please f2x request to 303-280-9848 <br />© check hers *o leave this section wank <br />Custnmari Cash - Colorado <br />? Check here to leave this section blank <br />Generator; Mt ebert Mining <br />A#Mt Addr¢ss: Various lacatione <br />City. State and zip: Various, <br />Phoft: <br />© Check here to Ism this section blank <br />Tratrsparkr; <br />Street Aefdress; <br />", state and 4: <br />PhI Ma: <br />US EPA Zd (if apPlitabke); <br />Name: R X y Bl ec.ti a <br />Manlfssts Nea&d (date; 'V'o <br />5trest Addmvx: WI Ilaw Creek Mine <br />CKY, state and 7jo I mdviile, CO WX61- <br />Phone;(803)266-8688 <br />? Check here to kove this section blank <br />Landfill: DAM <br />Frofila Number: =766CQ <br />Waste Descrrptlw Friable usbo tos cant PiPR <br />A"aIM NumbV' C L"05 <br />Now of Wividuai signing the Manifest; <br />Phoaa; 3d>':?• >''& - 9 w i? $ <br />A) %r <br />Mpflif*0s Needtd (TiMel: f Ao^d4j T'01' '1A- L?- <br />Number of Manifests Requested; i ** Please 91low a NaMMUM of 4 hours notice for printing if <br />less than 4 hours Please tall 720.977.2102 to check avOiabillty <br />k1k <br />'Up to 25 Manifests will be charged a total of $95.00 - mre than 25 Manitesta will be ch d $1.00 afch* <br />5hip'fo: 0 Customer` Up <br />© Generator IFOMIesDt pick Up is only available at tour <br />0 Londfil( office located at 7780 east 96'`' Avenue <br />4 NIA Henderson, CO) <br />Q Other; 0 Regular {kii (no additional charge) <br />? Overnight UP5 (additional $25 charge)* <br />U Priority Overnight (additional $50 charge)w <br />I "Orders must be petelved by 2 PM MST in order to be shipped for receipt the next business day :j