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r <br />139399 <br />WASTE MANIFEST <br />1. Generator's Name and Project Location <br />2. Bill to: <br />1 a. Generator's Phone <br />2a. Account # <br />3. Transporter 1 Company Name <br />3a. Transporter's Phone <br />4. Transporter 2 Company Name <br />4a. Transporter's Phone <br />5. Designated Management Facility Name and Site Address <br />5a. Facility's Phone <br />6. Waste Code/Profile # <br />Waste Description <br />Quantity <br />Units <br />G <br />E <br />E <br />R <br />A <br />T <br />IF ASBESTOS WASTE <br />(Please check the appropriate box) <br />0 <br />R <br />Waste Code/Profile # <br />Waste Description <br />Quantity <br />Units <br />Friable RQ Asbestos Class 9 NA 2212 PG III <br />Nonfriable Asbestos <br />7. Regulatory Agency: <br />Colorado Department of Public H <br />alth and Environment <br />Emergency Notification: CHEMTREC (800) 424-9300 <br />4300 Cherry Creek Drive South <br />24 hr. toll free phone number <br />Denver, CO 80222-1530 <br />8. Contractor/Generator Certification: <br />I hereby certify that the above describ <br />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 mate <br />ials. This waste has been accurately classified, described, packaged, marked and labeled and is in proper <br />condition for transportation according t <br />applicable international and governmental regulations. <br />tedfr el N <br />/\ <br />me i <br />AN <br />()Signature ' Month Day Year <br />\ill==` I <br />T <br />` i I h <br />�i�J 0 6 <br />R <br />A <br />9. Transporter 1 Acknowledgement of Recei <br />t of Materials <br />N <br />Printed/Typed N <br />me <br />Signature Month Day Year <br />S <br />P <br />0 <br />R <br />10. Transporter 2 Acknowledgement of Rec <br />pt of Materials <br />T <br />E <br />Printed/Typed N <br />me <br />Signature Month Day Ye <br />R <br />11. Discrepancy Indication Space <br />12. Ticket # <br />F <br />A <br />C <br />13. Management Method/Location ❑ So <br />idification ❑ Monofill ❑ Landfill ❑ Bio -Beds <br />1 <br />L <br />I <br />Grid Location (if applicable): <br />T <br />Y <br />14. Facility Owner or Operator: Certification of <br />r ceipt of waste materials covered by this manifest except as noted in item 11. <br />Printed/Typed Name Signature Month Day Year <br />CONTRACTOR'S COPY <br />