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■ c <br />O <br />20 <br />D <br />onservation Service: c. <br />®-WASTE <br />FFICES <br />FACILMY <br />TERMS: Net 30 days. Past due accounts <br />90 E. 104th Ave. <br />41800 E. 88th Ave. <br />✓ �' v � r � � • <br />enver. CO 80233 <br />CARRIER/DRIVER CND <br />Bennett, CO 80102 <br />(303)280-9336 <br />(303)1-W-4335 <br />Fax: 280-9848 <br />1-800-662-4089 <br />1-800-322-8405 <br />INDUSTRIAL WASTE DISPOSAL MANIFEST <br />C <br />PART I: TO BE COMPS FTED BY' SHIPPER/GENERATOR <br />GENERATOR'S NAME nh <br />%I <br />FAX <br />N° 092420 <br />• <br />®-WASTE <br />DESCRIPTION <br />CSI WASTE CODE NUMPER <br />TERMS: Net 30 days. Past due accounts <br />- ' <br />LTi' _ •_ ��. <br />✓ �' v � r � � • <br />PART II: TO BE COMPLETED BY <br />CARRIER/DRIVER CND <br />CARRIER NAME H�j/y <br />BUSINESS ADDRESS <br />PHONE NO.%J 7� 7Fjl <br />I certify that materials in the quantity described above <br />are received SIGNATURE OF <br />by me for the shipment to the facility listed below. <br />AUTHORIZED <br />AGENT <br />IMPEREEMEM <br />materials described above were consigned to the Carrier named SIGNATURE OF C <br />V. I certify that the foregoing is true and corrict to the best of my AUTHORIZED !� <br />,, Owledge. AGENT X_j —A <br />O % TYPE OR PRINT <br />DATE: <br />/ ABOVE NAME <br />TERMS: Net 30 days. Past due accounts <br />all accr a interest at the rate of 1.5% per month (18% per annum) until paid in full. CustomUrshall be <br />responsible for payment of all costs of coll <br />tion of past due accounts, including court costs and reasonable attorney fees. n? <br />PART II: TO BE COMPLETED BY <br />CARRIER/DRIVER CND <br />CARRIER NAME H�j/y <br />BUSINESS ADDRESS <br />PHONE NO.%J 7� 7Fjl <br />I certify that materials in the quantity described above <br />are received SIGNATURE OF <br />by me for the shipment to the facility listed below. <br />AUTHORIZED <br />AGENT <br />TYPE OR PRI <br />NA <br />DATE: <br />/ ABOVE <br />PART III: TO BE COMPLETED B <br />FACILITY OWNER OR OPERATOR <br />DISCREPANCY OR COMMENTS <br />�Ict_(J / <br />DISPOSAL ROUTE/LOCATION <br />KSOLIDIFICATION 0 DIRECT BURIAL D BIO -TREATMENT <br />^'4POSAL LOCATION <br />, „CILITY OWNER OR OPERATOR CON <br />ERVATION SERVICES, INC. <br />I certify that the materials in the quantity describe <br />in Part I are SIGNATURE OF�� <br />/'/w <br />received by me. <br />AUTHORIZED <br />AGENT X <br />TYPE OR PRINT <br />� 'Z112 Lew-, <br />DATE: I <br />L ABOVE NAME <br />WHITE • <br />IGINAL YELLOW . DISPOSAL FACILITY PINK - TRANSPORTER GOLD - GENERATOR 6/91 <br />