HomeMy WebLinkAboutNon-Hazardous Waste Manifest NON-HAZARDOUS WASTE MANIFEST JI J 2�� Q
AGEME If waste is asbestos waste,complete all Sections. . H O 0 L J
If waste is NOT asbestos waste,complete only Sections 1,2,3,4,and 5. Manifest No
GENERATOR INFORMATION(generator to complete) ,'° : 3
-aerator's Name:. j) Generating Location(Name):
City of Oak Park Heights SAME
b)Generator's Address: 5810 NorSli Ave North k) Address:.
Oak.Park Heights , 55082
Andrew Kegley yy
d Tele hone Number: 1
-439-4439
C) Generator's Representative: d) P
d)Telephone Number:
e)WASTE MANAGEMENT APPROVAL CODE i 03012MN
f) Common Name of Waste: Sandblast Abrasive Waste m)Asbestos ONLY-Q Friable; Q Both; %friable %non-friable
g)Description of Waste: 0 Non-friable; Q N/A
h) Disposal Volume: l(f , C.r n)Type of Containers: I How many TYPE of CANTAINERS
TR -TRUCK
v,
_Tons —Cubic Yards _Other DM-METAL DRUM
DP-PLASTIC DRUM
I) Number of Containers: BA -BAG
o)I hereby warrant that the�above named material la the same material as represented on the Special Waste Disposal Application BB -6 MIL.PLASTIC BAG
Identified;by the above Waste Management Code and such material was delivered to the transporter on the shipment date referenced BC -12 MIL.PLASTIC BAG c-,?4,4,,,,c1.,,,----`-
Generator's A razed Agent Name rin nature o enerator's Authorized Agent Shipment Date
T 0,'2 uuulllmfififi0000 eT N 3Rt',; T ,SECTION°3 ,IRAN °R° I Tff., " ° < :4 sus
a)Transporter's Name: 7 , ate-, ", -, .5 -)' 4-.:__ ' a)Transfer Facility's Name:
b)Transporter's Address: '�, f i K (.1 , b)Transfer Facility's Address:
C)Telephone Number: 2 ''� '. ` '"f c' v! ' ' '' 3 c) Telephone Number:
d)Vehicle License No./State: y '"- -t 4J .' - d)Vehicle License No./State:
e
e)Trailer or Container No.: I e)Trailer or Container No.:
� f) Name of Transfer Facility's
f) Name of Driver(print/type)--)`* r� sl c"'-, L-1-2,....7,`)C-.0 Authorized Agent(print/type)
g)I hereby warrant that the above named and described material was received g)fro hereby warrant transporter the h the dvee named ed receipt described below.
material was received
from the:gene for n ttje date of deliveW referenced below. r.
�1 ' ;r--( 6,-,.--'.---L'1.-i 7 -- _-,f /
Signore of Driver Date of Receipt Signature of Transfer Facility's Authorized Agent Date of Receipt
h)I hereby warrant that the above named and described material was delivered h)I hereby warrant that the above named and described material was delivered
wfthoulpOld../vspft or,coleminstion on Ihe date of delivery referenced below. referenced bpslow,without incident or contamination on the date of delivery
Si- ature of Driver Date of Delivery Signature of Transfer Facility's Authorized Agent Date of Delivery
a)Transporter's Name: a) Disposal Facility's Name: Spruce Ridge Landfill (SW-6)
b)Transporter's Address: b) Physical Address: 12755 137th St; Glencoe,MN 55338
c)Telephone Number: c)Telephone Number: 320-864-5603 i
d)Vehicle License No./State: d)Mailing Address: / A.(¢' ,
e)Name of Disposal Facility's '( FM,� iv . '1,\ k( _ / , 4•__„__
e)Trailer or Container No.: A razed Agent(grin ) VVV
0 T mate I delive b the Tfaian porter has ved tM
f) Name of Driver(print/type) ' 1 ' ! � _
g)I hereby warrant that the above named and described material was received ,fir- i t4'(--1-11 ' ---w � /
on the date of receipt referenced below. Signature of Disp I Facility's A orized Agent Date Receipt 1
g)The material del ered by the T nsporter has been rejected at the Disposal at
Signature of Driver Date of Receipt the Disposal F Ility. -
h)I hereby warrant that the above named and described material was delivered
on the delivery date referenced below. Signature of Disposal Facility's Authorized Agent Date of Rejection
Signature of Driver Date of Delivery Signature of Driver Date of Rejection
f :o, g. : ASBESTOS ratorto coin.late ., , .`:. ate..".
"Operator"is defined as the company which owns,leases,operates,controls,or supervises the facility being demolished or renovated,or the demolition or
renovation operation or both.
) a)Operator's Name: c) Telephone Number:
. b)Operator's Address:
d)Recommended special handling instructions and additional information:
e)Operator's Certification: I hereby warrant and declare that the contents of this consignment are fully and accurately described above by proper shipping name
and are classified, marked,and labeled,and are in all respects in proper condition for transport by highway according to applicable international and domestic
law,regulations,ordinances,orders,rules and/or standards.
Operator's Name(print/type) Signature of Operator's Authorized Agent Date
f) Responsible Agency
Name and Address:
WHITE-DESTINATION(Disposal Facility) CANARY-GENERATOR PINK-TRANSPORTER GOLD-GENERATOR
NON-HAZARDOUS WASTE MANIFEST �� ,,l I ��� 0 L
WA fiCMENT If waste is asbestos waste,complete all Sections. _. •
',0'6114,,A,,,,,, y °
nifest No If w as to i s N O T asbestos waste,complete only Sections 1,2,3,4,and 5
„0 i a ° ^a P7W :c a ° €:, ,,1,
a)Generator's Name:. j) Generating Location(Name):
i ' City of Oak Park Heights SAME
5810 Norell Are North
b)'Generator's Address: k) Address:.
Oak Park Heights , MN 55082
c) Generator's Representative: dfeV Kegley d)Telephone Number: i
d)Telephone Number: �•�1-439-4439 (s) 1 r,j i 3
a
t e)WASTE MANAGEMENT APPROVAL CODE 103012MN
i
f) Common Name of Waste: Sandblast Abrasive Waste m)Asbestos ONLY-
Q Friable; 0 Both; %friable ,:76non-friable
g)Description of Waste: // ` Q Non-friable; 0 N/A
h)Disposal Volume: �t ' G� n)Type of Containers: • How many T -TRUCK ERS
\f R TRUCK
Tons --Cubic Yards _Other DM-METAL DRUM
DP-PLASTIC DRUM
I) Number of Containers: BA -BAG
o)f hereby warrant that the�above named material is the same material as represented on the Special Waste Disposal Application BB -8 MIL.PLASTIC BAG
identified�dby the above Waste Management Code and such material 1 s delivered�to the transporter on the shipment date referenced BC '12 MIL.PLASTIC BAG
. ,
Generators Authorised Agent nre(pnnfnype)' a ure o : -re or s , • u:=• •en ;r.
,.
a)Transporter's Name: T ' ,-, t--p., t v7 L. k" G." .
a)Transfer Facility's Name:
b)Tranaporter's Address: b)Transfer Facility's Address: \
c)Telephone Number: s c) Telephone Number: iti
d)Vehicle License No./State: " `J ' d)Vehicle License No./State.
e)Trailer or Container No.: t 1 e)Trailer or Container No.:
.,S a ' f�_l:.-• (,.,.7'"- „< 0 f) Name of Transfer Facility's
I) Name of Driver(print/type) Authorized Agent(print/type) t
, g)I hereby warrant that the above named and described material was received 9)I hereby warrant that the above named and described material was received
from theigenliretor Jen she dat,of*oft,referenced wow. ( i from the transporter on the date of receipt referenced below.
Sielahlre of Driver Date of Receipt Signature of Transfer Facility's Authorized Agent Date of Receipt
h)I hereby warrant that the above named and described material was delivered h)I hereby warrant that the above named and described materiel was delivered
laf pt or on on pie dote of del n to the transporter without Incident or contamination on the date of delivery
,, Z-~; !. T,z- 7 referenced below.
) re of Driver Date of Deily Signature of Transfer Facility's Authorized Agent Date of Dative - .t
Traneporter's Name: a) Disposal Facility's Name: Spruce Ridge Landfill(SW-8) '
b)Transporter's Address: b)Physical Address: 12755 137th St;Glencoe,MN 55336
c)Telephone Number: c)Telephone Number: 320464 550
d)Vehicle License No./State: d)Mailing Address: SAME
e)N:me of Disposal Facility's C.(! L L Lii
L." ( w-
e)Trailer or Container No.: A zed Agent(printtype)
Q Matt a bf r(Printtype' f) I deli b t e has •
�. thereby warrant that fire above married and described material was reoelved ,,
on the date of receipt referenced below Signature of Dis••-: Facility's A • zed Agent Date Receipt
g)The material del red by the nsporter has been rejected at the Disposal at
Signature of Driver Date of Receipt the Disposal F INV. •
h)I hereby warrant that the above named and described material was delivered
on the delivery date referenced below. Signature of Disposal sposal Facility's Authorized Agent Date of Rejection...
Si e of Driver Date of Delivery Signature of Driver Date of Rejection
, " ' . V yr -%a vA614SINIMS MS"'AI 7. zr E . .,zu -...46-40.,k_ . 'n.,,,.. c
Operator"is defined as the company which owns,leases,operates,controls,or supervises the facility being demolished or renovated,or the demolition or
renovation operation or both.
I a)Operator's Name:
c) Telephone Number:
b)Operator's Address:
I d)Recommended special handling instructions and additional Information:
e) •
Operator's Certification: I hereby warrant and declare that the contents of this consignment are fully and accurately described above by proper none
r and are.classified,marked,and labeled,and are in all respects in proper condition for transport by highway according to applicable international and domestic
i law,regulations,ordinance.,orders,rules and/or standards.
Operator's Name(print/type) Signature of Operator's Authorized Agent Date
f) Responsible Agency
Name and Address:
WHITE-DESTINATION(Disposal Facility) CANARY-GENERATOR PINK-TRANSPORTER GOLD-GENERATOR
NON-HAZARDOUS WASTE MANIFEST ' ' al-{ II • �'
WARTA MANAGEMENT If waste is asbestos waste,complete all Sections. r
/ If waste is NOT asbestos waste,complete only Sections 1,2,3,4,
,� ." I If N .�0630
*;NNi GENERATOR INFORMATION ,.aerator to Complete, ae a 4
aA»
a) Generator's Name:. j) Generating Location(Name):
City of Oak Park Heights SAME
b)Generator's Address: 5310 Norell Ave North k) Address:.
Oak Park Heights , MN 55082 '" ""
c) Generator's Representative: Andrew Kegley d)Telephone Number:
d)Telephone Number: 651-439-4439
e)WASTE MANAGEMENT APPROVAL CODE 103012MN
f) Common Name of Waste: Sandblast Abrasive Waste m)Asbestos ONLY-Q Friable; Q Both; —%friable %non-friable
g)Description of Waste. _ Q Non-friable; Q N/A TYPE OF CONTAINERS
h)Disposal olume: �k_r ' i \ ,S ` n)Type of Containers: l How many
////// TR -TRUCK
_Tons _Cubic Yards _Other DM-METAL DRUM
DP -PLASTIC DRUM
I) Number of Containers: BA -BAG
o)I hereby warrant that the above named the same material as represented on the Special Waste Disposal Application BB 8 MIL.PLASTIC BAG
BC
identified by the above Waste Management Code and such material was delivered to the transporter on the shipment date referenced '12 MIL.PLASTIC BAG
bolas, , A t,i •
zed D i)2 �,wllu /� >�'u�L �'/) I �"-" I'
Genera r s Authors Agent ame p nt/type) E a ure•- nera or s " or¢:. gen shipment Date
-�..`7 TR 0-°.. - 1,-- . ' , ' , ',SECTIONS ;.,TRANSFER PAC=• 'E- •2 14,, .,3 :.ate .�a�. h 4 [<•
a)Transporter's Name:T'-'-`' P"`G'"►
� a)Transfer Facility's Name:
b)Transporter's Address: a %$ '" �`+ ') ) `� b)Transfer Facility's Address:
c)Telephone Number: 3 1/ `I`d—7 5'1 3 c) Telephone Number:
d)Vehicle Ucense No./State:µ�.5>' > m d)Vehicle License No./State:
e)Trailer or Container No.: I'"I e)Trailer or Container No.:
f) Name of Transfer Facility's
f) Name of Driver(print/type)-"e /2 '—. ' '-2,: a a Authorized Agent(print/type)
g)1 hereby warrant that the above named and described material was received g)I hereby warrant that the above named and described material was received
fro I�r r o the of del very referenced bel from the transporter on the date of receipt referenced below.
ture of Driver Date of Receipt Signature of Transfer Facility's Authorized Agent Date of Receipt
h)I hereby warrant that the above named and described material was delivered h)I hereby warrant that the above named and described material was delivered
inside—t or ntamination�ogn the date of delivery referenced below. to the transporter without Incident or conteminstlon on the date of delivery
I. ii.4, — Lrt �z..X // referenced below.
S_flature of Driver Date of Delivery Signature of Transfer Facility's Authorized Agent Date of Delivery
;:° .''A. P T ANSPOR1'ER2 . EA•e•'licetle . SECTION � DESTINATION' 'FA' .r �PT?'2:P &
a)Transporter's Name: a) Disposal Facility's Name: Spruce Ridge Landfill (SW-6)
b)Transporter's Address: b) Physical Address: 12755 137th St; Glencoe,MN 55336
c) Telephone Number: c)Telephone Number: 3204134`5503
d)Vehicle Ucense No./State: d)Mailing Address: t 'SA''
e)Name of Disposal Facility's tL ■ fivr 1 J
e)Trailer or Container No.: Authorized Agent(prin ) _ rum
f) Name of Driver(print/type) n' mete I delive aby the rensporter has nn read • at th Disposal
g)I hereby warrant that the above named and described material was received , e L- 1• 1..._____—. /' 1 • l /
on the date of receipt referenced below. Signature of Die I Facility s oriized Agent Date of Receipt
g)The material de ered by the Transporter has been rejected at the Disposal at
Signature of Driver Date of Receipt the Disposal F ility.
h)I hereby warrant that the above named and described material was delivered
on the delivery date referenced below. Signature of Disposal Facility's Authorized Agent Date of Rejection
Signature of Driver Date of Delivery Signature of Driver Date of Rejection
.E. ASBES' o<eretor to corn tote �m
"Operator"is defined as the company which owns,leases,operates,controls,or supervises the facility being demolished or renovated,or the demolition or
renovation operation or both.
a)Operator's Name: c) Telephone Number:
b)Operator's Address:
d)Recommended special handling instructions and additional information:
a)Operator's Certification: I hereby warrant and declare that the contents of this consignment are fully and accurately described above by proper shipping name
and are classified, marked,and labeled,and are in all respects in proper condition for transport by highway according to applicable international and domestic
law,regulations,ordinances,orders,rules and/or standards.
Operator's Name(print/type) Signature of Operator's Authorized Agent Date
f) Responsible Agency
Name and Address:
WHITE-DESTINATION(Disposal Facility) CANARY-GENERATOR PINK-TRANSPORTER GOLD-GENERATOR
- - - - - -
,,.. i,. 1...-
\ , NON-HAZARDOUS WASTE MANIFEST ';' t-I 7.( y -- ,y., • J _..a. n „1 el
w GEMENT If waste is asbestos waste,complete all Sections. ..„,.' ,,...-2,.. 1 4,- _iiili,41 TO' U 0 a U
If waste is NOT asbestos waste,complete only Sections 1,2,3,4,11nd-6( r '- •'''' "Run . --,----- - ,
--nazzi-r,„ , i , !!,, ..v=„zr,*).A„.,,c,,,,...46111011A13.: :',„ -''''', , ''''• '
a)Generator's Name:. j) Generating Location(Name):
•t• City of Oak Park Heights SAME
b)Generator's Address: 5810 Nora Ave North k) Address:.
Oak Park Heights , MN 55082 AUG —4 2(1 1 1
Kegley c) Generator's Representative: Andrew Ke-o .• d)Telephone Number:
051-4394430 . ,
d)Telephone Number: •
e)WASTE MANAGEMENT APPROVAL CODE 103012MN - - ,
f) Common Name of Waste: Sandblast Abrasive Waste m)Asbestos ONLY-E] Friable; El Both; -%friaBle -%non-friable
g)Description of Waste:\/ V I= Non-friable; El N/A
h)DisposaliVolume. k- 1
. r . V-"--),, c,.-,) n)Type of Containers: I How many ner.QESIMIARana
TR -TRUCK
DM-METAL DRUM
__Tons ----Cubic Yards --Other
DP-PLASTIC DRUM
I) Number of Containers.
BA -BAG
,..,
_BB :%MIL.PlASTIC BAG
0)1 hereby warrant that the above named 2...a:1:the same material as represented on the Special Waste Disposal Application
MIL.PLASTIC BAG
Identified by the above Waste Management Code and such material was delivered to the transporter on the shipment date referenced
-- - 4- 4' 't / 1 * ,e _
n rrUait tie WIt;,.'per
or s Autho erne' . t',FT.-•ure o"c:nera or s ■ . “ •. "' 7-.' '7
40 ,10 .771EZZ
a)Transporter's Name:77-- --, s E a)Transfer Facility's Name:
b)Transporter's Address:9 -.1 --) 5.- C- /- , ‘1 . '''' ' I 1 b)Transfer Facility's Address:
c)Telephone Number: 7 ' LI 7 '6- 7 5‘7. 3 c)Telephone Number:
d)Vehicle License No./State:LaZ >-__2.-- d)Vehicle License No./State.
...
e)Trailer or Container No.: I"'I e)Trailer or Container No.:
/
f) Name of Transfer Facility's
f) Name of Driver(print/type) ii c /4:1,...-,., (---t."7, c, c_e Authorized Agent(print/type)
k g)I hereby warrant that the above described was received g)I hereby warrant that the above named and described materiel was received
fro ti,i, spoii-r---ii-th-i- of receipt ,
4VerriZirmtri:Y 47--L
re of Driver Date of ipt Signature of Transfer Facility's Authorized Agent Date of Receipt
of Driver, h)I lullaby~rant that the above named and described material was delivered
h)itohihrrtrans rat thsullincideint or cOuld dese on on the wictfartrwmed '
j without InsIdept or- , ruination 1 the date of delljter! nced below. referenced boom _
Data r Delive Signature of Transfer Facility's Authorized Agent D
I
a)Transporter's Name: I a) Disposal Facility's Name: Spruce Ridge Landfill(SW4)
1
b)Transporter's Address: b)Physical Address: 12755 137th St;Glenme,h01 55336
-
c)Telephone Number: c) Telephone Number: 3204045503
a ,
d)Vehicle License No./State: d)Mailing Address: SA.
No.:
e)Trailer or Container e)Name of Disposal Facility's UNIMIIMpliint align!'
Authorized Agent(pri . ) 'WA= 'm-wim
1 fr h mat71 dell , by the nsPerter has - . at
f) NriffrolAtiver(prietljekeh- , , T . / „..---) ,...„ /
g)I hereby warrant that the above named and described material was received '''',. ' f'., , At . ..r ( ,• f/, 1,
on the date of receipt referenced below. Signature of D ;.-. Facility's A thorized Agent Date of Receipt
g)The material . •red by the Transporter has been rejected at the Disposal at
Signature of Driver Date of Receipt the Disposal F Sky.
h)I hereby warrant that the above named and described material was delivered
on the delivery date referenced below. Signature of Disposal Facility's Authorized Agent Date of Rejection
e of Driver Date of Delivery Signature of Driver Date of Rejection
"Operator"Is defined as the company which owns,leases,operates,controls,or supervises the facility being demolished or renovated,or the demolition or
/ renovation operation or both.
a)Operator's Name: c) Telephone Number:
r,
i b)Operator's Address:
d)Recommended special handling instructions and additional information:
e)Operator's Certification: I hereby warrant and declare that the contents of this consignment are fully and accurately described above by proper shipping name
and are classified,marked,and labeled,and are In all respects In proper condition for transport by highway according to applicable international and domestic
(aw,regulations,ordinances,orders,rules and/or standards.
1
Operator's Name(print/type) Signature of Operator's Authorized Agent Date i
f) Responsible Agency
Name and Address:
WHITE-DESTINATION(Disposal Facility) CANARY-GENERATOR PINK-TRANSPORTER GOLD-GENERATOR
v y NON-HAZARDOUS WASTE MANIFEST /� `,
WASTE MANAGEMENT If waste is asbestos waste,complee all Sections. 80659
If waste is NOT asbestos waste,complete only Sections 1,2,3,4,and 5. Manifest No.
e',7.ar 1.`.' „E_ ° A , `.GENERATOR• *.- , TIoN(generator toico,npfetis), , , ._, - w1;`' 1
a)Generator's Name:. k4 j) Generating Location(Name):
City of Oak Park Heights SAIMME
b)Generator's Address: 5810 Norell Ate North k) Address:.
Oak Park Heights , MN 55832
Andrew Kegley A '
c) Generator's Representative: d)Telephone Number:
d)Telephone Number: 651
e)WASTE MANAGEMENT APPROVAL CODE 10301 2MN
f) Common Name of Waste: Sandblast Abrasive Waste m)Asbestos ONLY-
Q Friable; 0 Both; -%friable %non friable
g)Description of Waste: 0 Non-friable; 0 N/A
h)DI //// n)Type of Containers: I How many TYPE OF CONTAINERS
sposa Volume:
TR -TRUCK
_Tons Cubic Yards _Other DM-METAL DRUM
I) Number of Containers: DP -PLASTIC DRUM
BA -BAG
o)I hereby warrant that the abo named material Is the same material as represented on the Special Waste Disposal Application BB -B MIL.PLASTIC BAG
identified by the above Waste Management Code and such material was delivered to the transporter on the shipment date referenced -12 MIL.PLASTIC BAG
7''"� 4,LI RNU 10 0 � t
enerator s or zed gent Name(print/type) na ure o enerator s Authorized Agent Shipment Date
. . .°!,ti TRANSPORTER TRAsspbRTER 1 ,. ! SECTiON13 TRANSFER..t*ACilT9. iete C',-4 s
a)Transporter's Name: -1 i )"` f'”or`--, ct
a)Transfer Facility's Name:
b)Tran e^] r?
iH sr NON-HAZARDOUS WASTE MANIFEST '" ue' i
If waste is asbestos waste, 80659
W 0!MlNT cxrmptefe all Sections. Manifest No.
If waste is NOT asbestos waste,complete only Sections 1,2,3,4,and 5
, .,...:;;: B : a_. „;,I.C.,' t :L ,,r' ,gy m .,:W.. r P� 'a,' - _'+
a)Generator's Name:. j) Generating Location(Name):
City of Oak Park Heights SAME
b)Generator's Address: Norell $North k) Address:.
Oak Park Heights , MN 55082
Andrew Kegley
ac) Generator's Representative: 115 t� S g d)Telephone Number:
d)Telephone Number: ;
z e)WASTE MANAGEMENT APPROVAL CODE 103012M ' n A;
f) Common Name of Waste: Sandblast Abrasive Waste m)Asbestos ONLY-
Q Friable; Q Both; %Motile % ,
g)Description of Waste:
//// �1 �ti.1 "r ,..._. . Q Non-friable; Q N/A
h)Disposal/Volume: J n)Type of Containers: ®� How many TRUCK
AINERS
yy_�� Tons Cubic Yards _Other DM-METAL DRUM
n Number of Containers: DP•PLASTIC DRUM
BA •BAG
o)I hereby warrant that the abo named material Is the same material as represented on the Special Waste Disposal Application BB :113,,M4-1;PLASTIC BAG
identified by the above Waste'Management BC L.PLASTIC BACi
` Bement Code and such material +a dalivgtpdA transporter on the shipment date referenced . i
iC/ {j,YJj .
Generator's Authorized Agera,Name(piewtypei 0., ture of Generator's Authorized Agent Shipman Date v'+ 9
'
a)Transporter's Name: �) -r+, k' a �1 a)Transfer Facility's Name:•b)Transporter's'Address:7 6 3 `( cf �. `f - b)Transfer Facility's Address:
c)Telephon?Number: w `w . c)Telephone Number: ,
d)Vehicle License No./State: '' '// a
! d)Vehicle License No./State: ;
e)Trailer or Container No.: L l t e)Trailer or Container No.: f '
f) Name of Driver(print/type) I, e I 1 �-� E."-}',v f) Name of Transfer Facility's ,01
Authorized Agent(print/type)
co I hereby!want the above named a described material was received g)I hereby warrant that the above named and described materiel was received 7
fro r on 1M deg referenced below. from the transporter on the date of receipt referenced below.
Signature of Driver Date of Receipt Signature of Transfer Facility's Authorized Agent Date of Receipt
h)I warrant that the above named and described material was delivered h)t hereby warrant that the above named and described material was Mahrered
i or inado on the date of del trlow, to Mr transporter without incident or con on t e dale of dNtwry
V -'T„. r --- r / _ referenced bMOW.
Lure of Driver Date of Delhi Signature of Transfer Facility's Authorized Agent Date of'bet e
a)Transporter's Name: a)Disposal Facility's Name: Spruce Ridge Landfill(SW-8)
b)Transporter's Address: b)Physical Address: 12755 137th St;Glencoe,MN 56330
c)Telephone Number: c)Telephone Number: 320.884.5503
•
d)Vehicle license No./State: d)Mailing Address: E
e)Trailer or Container No.: e)Name of Disposal Facility's NW i
Authorized Agent(print/type)
Fato m* rial deli by Transpdrter 7ai'g'w'r'�'!"f the
fl Name of Driver(print/type) ( q
g) the above and described material was received ' t_. �- V•1” ,1,,,.✓"' t ' ' t 0a
Signature g of Dis sal Facility's thorized Agent Date of
g)T material del red by the Transporter rhhas been rejected at the Disposal at
Signature of Driver Date of Receipt the Disposal Facility.
h)I hereby warrant that the above named and described material was delivered
on the,delivery date referenced below. Signature of Disposal Facility's Authorized Agent Date of Rejection
0.
e of Driver Date of Delivery Signature of Driver Date of Rejection
"Operator"is defined as the company which owns,leases,operates,controls,or supervises the facility being demolished or renovated,or the demolition or I'
renovation operation or both.
a)Operator's Name: c) Telephone Number.
b)Operator's Address:
} .'
d)Recommended special handling instructions and additional Information:
•)Operator's Codification: I hereby warrant and declare that the contents of this consignment are fully and accurately described above by.propfashipping name
and are classified,marked,and labeled,and are in all respects in proper condition for transport by highway according to applicable Inbmealtiioonnal and domestic I
law,regulations,ordinances,orders,rules and/or standards. ,
Operator's Name(print/type) Signature of Operator's Authorized Agent i, Date <I.14
f) Responsible Agency
Name and Address:
WHITE-DESTINATION(Disposal Facility) CANARY-GENERATOR PINK-TRANSPORTER GOLD-GENERATOR ,y'1