2011-04-11_GENERAL DOCUMENTS - P2008046

• Permit No: P2008046
• IBM Index Class Name: GENERAL DOCUMENTS
• Doc Date: 4/11/2011
• Doc Name: Request to bury drill cutting from TM drilling under TM pad
• From: American Shale Oil, LLC
• To: DRMS
• Email Name: THM
• Email Name: DB2
• Media Type: D
• Archive: No

V. Laboratory Information
1. Laboratory Name: Evergreen Analytical (now Accutest Laboratories)
2. Contact Person: Shea Greiner Phone:[phone] Fax: --- Email:
[e-mail]
3. Attach results and chain of custody documentation for all analyses performed on the subject waste
within the previous 12 months. For analytical requirements, please contact Bill Brown at KRW
Consulting, Inc., [phone].
VI. Random Sampling
Rio Blanco County performs random sampling and analysis for hazardous waste characteristics and
constituents of wastes provisionally accepted at the site. If your waste is selected for random sampling, a
sample will be collected at the time of receipt of the waste. If the results of random sampling and
analysis indicate that the waste was hazardous, the Generator shall be financially and legally responsible
for retrieval, transport, and disposal of the waste and all media contaminated by the waste at no cost to
Rio Blanco County. By execution of this document, the Generator agrees to indemnify Rio Blanco
County from, and agrees to defend Rio Blanco County against, all liabilities associated with the handling
of Generator's hazardous waste. in addition the Generator shall be responsible for all cleanup costs
associated with contamination of Rio Blanco County's landfill facilities as a result of delivery of
hazardous waste to the facility.
Vil. Certification
1 hereby certify that I am the Generator, or I am authorized by the Generator to provide the information
submitted in this form including any attached documents and to enter into this Agreement on the
Generator's behalf. I have made a complete and thorough investigation of all matters relevant to
completion of this form. This investigation Included laboratory analysis, where applicable, performed in
accordance with 6CCR 1007-3 Section 261.20(c) on a representative sample of the waste. All required
information concerning the waste, including the results of all laboratory analyses has been provided in
this and the attached documents. I further hereby certify that such information is complete and accurate
and that all known or suspected hazardous constituents/characteristics or safety hazards associated with
the waste have been disclosed herein. I understand that the waste may be subject to random sampling
and conditions described in Section VI of this form, that any waste that is non-conforming (along with the
reagent with which Rio Blanco County has mixed the waste) will be returned to me, and that Rio Blanco
County will not be responsible for expenses related to transportation, storage and handling of the non-
conforming waste.
Name: Roger L. Day ROGE ?
(Print or type) (Signature)
Title: Vice President of Operations
Date:_ X 3 J-UL. , WO ,7
Vill. Waste Acceptance
The waste, as represented by information contained In this document, is provisionally accepted for
disposal at Rio Blanco County Landfills (see Sections VI and VII of this form).
Waste Identification Code (assigned by Rio Blanco County): y0 Z ?7 Date: 7/j-7 jog
Signature of Authorized Rio Blanco County Representative: r .----?'
IX. WasteiReiection
The west as represented b nformati n contained in this
Blanco C unty Landfill r the following easons:
Signature of Authorized Rio Blanco County Representative
is not accepted for disposal at Rio