SKMBT_60119012314451Pink Cor)y - Transporter
kAlhite cop)y - Yeflovv Copy - Gereratu i
DEM-CON LANDFILL, LLC
Manifest #
536 0
WASTE MANIFEST FORM
Work Sit7� Name and Mailing Address:
Owner's Name:
4.1
Owns r Telephone:
Gen er.-,kor/Contractor- Name,, and Mailing Address:
Generator/Contractor Contact:
M 1 1
fF ull"A
G� any rator/Contractor Tdephone:
3
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3. Name anc Adds ass of Rcsporisible Agency: MPCA
Agency 's T(-Jephone:
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520 Lafayette Road North
(651) 296-6300
St Paul, MN 55155
A
4., Waste Disposal Ste: Dem-Con Landfill
Dem-Con's Telephone;
T
3601 West 1.30"' Street
(952) 445-5755
Shakopee, MN 55379
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15, Description of Materiaks: 6. Total Quantity:
T Special Handling/Additional mfo..
CY I-ON
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8. Gen*mator/Contr rCelfficatioav nsignment are fully and aCCLJrat(,'lY des -i U�d above by
prolau- shipping narm and arc, c!as.-;ified, jaa6ed, ji)arkad and labeled, and arc, in all respects in Proper condition for transporl, by highway
according to applicable international and nadonal government Iregulations. I further c(!rtify thal the contents ofthr consignment do not contain
hazardou,-i waste as defined ir 40 CTR Part )61,
Drhit(,:d Narne: i.l,:: Signa"Ure:
Da e.
`rirrsoo Wi I (A(klowlcdgen ant of f':Ceipt of �ilate, i'lls)
Narne
Truck JI
Onl'ruck,
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--N-unnber.
C Dnv.--!r's llrint,-,(J Name:
igrai ire;
S
1 ran ,;Po,te! Y', AClCrE!s,-"
Telephone. Date:
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j U), -h -a a spol fi=r -ia
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10n-ipany & Pfr)ne: Truck Narne, Nurnbe, A Drive,
Signature and Date:
F
Intficanxi spacx:,
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-1i Certification ofmaterials, cox fay
vjast(- oisDos,! SiCC, ovvn�--,- or Wer, ot
rm nifPA ,,xoopt as noted in itern 11.
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at a.
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Pink Cor)y - Transporter
kAlhite cop)y - Yeflovv Copy - Gereratu i