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Home My WebLink About20220534.tiffRESOLUTION RE: APPROVE THREE (3) APPLICATIONS FOR REIMBURSEMENT FOR PETROLEUM STORAGE TANK REMEDIATION (1113 H STREET FUELING FACILITY) AND AUTHORIZE CHAIR TO SIGN WHEREAS, the Board of County Commissioners of Weld County, Colorado, pursuant to Colorado statute and the Weld County Home Rule Charter, is vested with the authority of administering the affairs of Weld County, Colorado, and WHEREAS, the Board has been presented with Three (3) Applications for Reimbursement for Petroleum Storage Tank Remediation from the County of Weld, State of Colorado, by and through the Board of County Commissioners of Weld County, on behalf of the Fleet Department, to the Colorado Department of Labor and Employment (CDLE), Division of Oil and Public Safety, commencing February 7, 2022, with further terms and conditions being as stated in said applications, and WHEREAS, after review, the Board deems it advisable to approve said applications, copies of which are attached hereto and incorporated herein by reference. NOW, THEREFORE, BE IT RESOLVED by the Board of County Commissioners of Weld County, Colorado, that the Three (3) Applications for Reimbursement for Petroleum Storage Tank Remediation from the County of Weld, State of Colorado, by and through the Board of County Commissioners of Weld County, on behalf of the Fleet Department, to the Colorado Department of Labor and Employment (CDLE), Division of Oil and Public Safety, be and hereby are, approved. BE IT FURTHER RESOLVED by the Board that the Chair be, and hereby is, authorized to sign said applications. The above and foregoing Resolution was, on motion duly made and seconded, adopted by the following vote on the 14th day of February, A.D., 2022, nunc pro tunc February 7, 2022. BOAWD OF COUNTY COMMISSIONERS �,�,` WE CO NTY, COLORADO ATTEST: 1� G:.aC.Gt�►•tkIt.-., S tt K. James, Chair cc:S(rr/s6) Ac1(cP/cD) 2022-0534 o2 /a.2/22 BG0024 COLORADO PETROLEUM ORIGINAL REIMBURSEMENT APPLICATION STORAGE TANK FUND Tank Owner/Operator (2017) THIS FORM MUST BE USED FOR THE ORIGINAL APPLICATION FOR REIMBURSEMENT. After the Applicant has established eligibility, Short Form S is used. IAP # [l1L/OPS Internal Use only Applicant Entity Type: ` Government Event # 14027 Applicant's Full Le at Name' ' Weld County Government Social Security # or Federal Tax ID # 84-6000813 Contact Person: Barbara Connolly Phone # (970) 400-4445 Fax # Mailing Address (must match (. Street: 1150 O Street City: Greeley State CO Zip: 80631 Email: bconnotly®we(dgov.com Reimbursement Mailing Address (if different, must match Remit on W-9): Remit Entity: Street' City: StateZip: Email W-9 Information: is the applicant a new applicant to the Fund? Yes Site Name: Weld County Fueling Facility Site Address: Street: 1113 H Street City: Greeley State: CO Zip: 80632 Site Ownership History: Applicant acquired site on [date] 11/22/89 from [name] Unknown is the site teased? Current owner of site, if not applicant: Name: Phone# Address: Date Acquired List all known previous owners of site, dates of ownership and property usage: Complete this section only if you want the representative to be the primary contact and copied on all correspondence, Applicant's Representative (if applicable): Name Palmetto Environmental Group Address 4995 York St City Denver State CO Zip 80216 Email: mail@patmetto-environmental.com Phone # 303.825.8117 Fax # Total from Listing of Costs, last column: $9,980.10 Less reimbursement from any other source (see #4): NET REIMBURSEMENT REQUEST: $9,980.10 Dates of work covered by this Application: From: 4/7/21 To: 5/6/21 . ForOP5 Use Only Facility iD:: OPS Technical. Reviewer Date Received by 0PS Event ID: OPS.Fund Analyst: C)PS Revised From Date Revised. To Date Amount After Converted Revisions Revised 8/4/17 `Prior versions of this application will not be accepted Page 1 of 4 RELEASE INFORMATION "Release" means any spilling, leaking, emitting, discharging, escaping, leaching, or disposing of a regulated substance from an aboveground or underground storage tank into groundwater, urface water, or soils. fCRS 8-20.5-101 (14): § 8-20.5-303(111 this release ed by a third rN O IT so, provide the name of the third - party and their REIMBURSEMENT INFORMATION 2 Will there be additional reimbursement applications for this release? Yes 3 Except for any contractual relationship established in response to this remediation, is there any relationship - personal, financial, or otherwise - between Applicant and any company or person who performed work for which reimbursement is claimed? If yes, explain: No 4 Has Applicant received, or does Applicant expect to receive, compensation for corrective action costs from ANY source other than the Colorado Petroleum Storage Tank Fund, including lawsuits, insurance settlements (other settlements including third -party), judgments, insurance contributions from other parties? If yes, state amount of other reimbursement: No $ . Identify source of reimbursement, including court case name and number, if applicable: 5 I List all insurance policies covering this site at date of release - include additional page(s), if necessary).: carrier Name: County Technical Services Policy # Colorado Counties CAPP Phon Agent's Name: Effective Dates: 1/1/21 - 1 Does policy cover cleanup of petroleum contamination? Carrier Name: Policy # Agent's Name: Effective Dates: Does policy cover cleanup of petroleum contamination? M Provide the Information below for any applicable insurance policy: Policy Number I Deductible I Amounts Paid to Date Phone # Amounts Claimed and/or Expected to be Paid in the Future any costs claimed for reimbursement represent work performed by the Applicant or Applicant's employees? If , submit the Affidavits Regarding Work Performed by Applicant or applicant employees. 8 Has any other Applicant sought reimbursement for costs incurred for this release? If yes, explain. , 4l Include other Applicant's name, address, phone number, and Reimbursement Application number(s): No No RevIsed 8/4117 *Prior versions of this application will not be accepted Page 2 of 4 By submitting this application, the Applicant affirms, certifies and agrees as follows: 1. The Applicant certifies, under penalty of law, that Applicant Is the appropriate person to request reimbursement, and that this document and all attachments were prepared under Applicant's direction or supervision in accordance with a system designed to assure that qualified personnel properly gathered and evaluated the information submitted. 2. The Applicant is the Owner/Operator or duty authorized agent of the Owner/Operator responsible for this Site. The Applicant is end shall be responsible for assuring compliance with all applicable State and federal regulations. 3. The information submitted by the Applicant, to the best of Applicant's knowledge and belief, is true, accurate and complete. Applicant understands that this Application will be submitted by the Colorado Department of Labor and Employment (COLE or State) for consideration by the Petroleum Storage Tank Committee (Committee). Upon demand by the Committee, Applicant agrees to return the entire award Applicant may receive or any other amount the Committee considers appropriate If (a) Applicant misrepresented or omitted any fact, either in writing or orally, relevant to the determinations made by the Committee or the COLE; or (b) Applicant falls to complete, to the Committee's or the CDLE's satisfaction, the corrective action. 4. The Applicant shall not be entitled to obtain any other reimbursement from any source other than the State for the same costs or work reimbursed by the State. Any reimbursement the Applicant receives or is entitled to receive, including Insurance proceeds, is and shall be the property of the State of Colorado to the extent of payment(s) made to the Applicant by the State from the Petroleum Storage Tank Fund. Upon receipt of any such reimbursement from a source other than the State, Applicant shall Immediately report and pay such reimbursement to the State. 5. To the extent payment is made from the Petroleum Storage Tank Fund, the Applicant hereby assigns to the State of Colorado any rights the Applicant may have which may allow the Applicant to seek and obtain recovery from any other entity for the costs or work reimbursed by the State, including the right to recover from insurance companies. 6. The Applicant shall not submit any further claims for reimbursement from the State for the Site(s) and work Identified in this Application, other than an amendment to the Application or protest of the Fund Payment Report, if any, for work not heretofore reimbursed. 7. Applicant shall indemnify, save, and hold harmless the State, its employees and agents, and the Committee against any and all claims, damages, liability and court awards including costs, expenses, and attorney fees and related costs, Incurred as a result of any act, omission or misrepresentation by the Applicant, or its employees, agents, subcontractors, or assignees pursuant to the terms of this Application. As to governmental entity Applicants, no term or condition of this Application shall be construed or Interpreted as a waiver, express or Implied, of any of the immunities, rights, benefits, protection, or other provisions, of the Colorado Governmental Immunity Act, CRS 2410- 101 at seq., or the Federal Tort Claims Act, 28 U.S.C. 2671 et seq., as applicable, as now or hereafter amended. 4, In addition to any other legal rights the State of Colorado may have, the State shall have audit and on -site Inspection rights for 3 years after payment 9. The remedlation services and supplies far which expenses are listed in this Application were performed and/or purchased at the most reasonable rates available for compliance. 10. The Applicant shall provide all formal or informal environmental assessment information to any future owner upon request. 11. In the event the Applicant breaches any of the terms, conditions or requirements of this Application, the State of Colorado, In addition to any other remedies, at law or equity, shall be entitled to immediate repayment on demand of all amounts paid to the Applicant, and in the event that the State is required to take legal action to enforce any of the provisions contained herein, the State shall be entitled, in addition to damages, to Its costs and reasonable attorney fees and related expenses Incurred in connection with such enforcement. 12. At all times during the performance of this remediation, the Applicant shall strictly adhere to all applicable federal and State laws, rules and regulations that have been or may hereafter be established, Including without limitation 42 U.S.C. 6991 and CRS 8-20.5-101, at seq., and associated regulations. 13. The State may allocate more or teas funds to the remedlatlon described in this Applicattonnthen the amount requested by the Applicant. Once the reimbursement request is approved, the State will issue a Fund Payment Report, substantially in the form of Exhibit B, documenting the amount that will be processed and paid. 14. The Committee has the authority and the right to designate funds be paid to Applicants on pro -rate basis when the Petroleum Storage Tank Fund balance prevents payment in full, pursuant to CRS 8-20.5-206(e)(2). 15. Each additional request by Applicant for reimbursement from the Petroleum Storage Tank Fund must be submitted on a new supplemental application. Any additional payment by the State shalt be conditioned upon the issuance by the Committee of a new Fund Payment Report for payment. 16. Pursuant to 7 CCR 1101.14, Article 8, the Applicant may file a protest of the Fund Payment Report If the Applicant disputes a decision by the Committee, as stated on the Fund Payment Report. The Applicant may petition the Committee to review Its decision. A Protest must be submitted within 60 days of the date of the Fund Payment Report. See 7 CCR 1101-14, 8-6. The Applicant shall use the form of Protest of Fund Payment Report provided by the Division of Oil and Public Safety of the Colorado Department of Labor and Employment. 17. The maximum amount to be paid by the State, If any, in connection with this reimbursement request shall be authorized by the Committee in the Fund Payment Report. 18. The payment by the State and acceptance by the Applicant of any reimbursement amounts requested sunder this Application shall be deemed to be good and sufficient consideration for the promises, certifications and affirmations made by Applicant in this Application. Revised 814117 -Prior versions of this applicallon urn not be accepted Page 3 of 4 Signatory Page Weld County Government Legal Name of Applicant 845000813 Scott K. James, Chair - Board of County Commissioners Print Name a Title of Authorized Officer Complete If this Is a replacement signatory page RAP# FACILITY ID# EMAIL TO: Idle PSTReimbursementAnosostate.co.us If you have any questions please consult the OPS website and/or contact OPS at (303) 318-8510. OPS websfte: htto./lwww cotorado.gov/oos REV 01411.7 -Prior versions of thla appfcauon wIII not be accepted Page 4 of 4 PALMETTO ENVIRONMENTAL GROUP LLC Affidavit: Proof of Payment (Revised 1/5/2016) This form should be used when an applicant submits an affidavit as proof of payment for costs claimed for reimbursement. This form is not required if copies of canceled checks or other bank confirmations of payment are provided. Please note the following requirements. • This form must be reproduced on the company letterhead of the payee (not the applicant's letterhead). o Affidavits that are not on the payee's letterhead will not be accepted. • This form must be signed by the payee, not the applicant. • Use a separate affidavit for each contractor. • Do not use this form if there is any affiliation or relationship between the applicant and the payee. More information is available in Section 8-2 (b) (2) of the Petroleum Storage Tani R -¢nations. Applicant Information Applicant Name: Weld County Government Site Name: Weld County Fueling Facility Site Address: 1113 H Street City: Greeley State: CO ZIP: 80632 Payee Information and Certification Check the following, as appropriate. ® I, being first duly sworn upon oath and being of lawful age, state that the following invoices relative to the referenced application for reimbursement from the Colorado Petroleum Storage Tank Fund have been paid in full by the applicant. O I, being first duly sworn upon oath and being of lawful age, state that the following invoices relative to the referenced application for reimbursement from the Colorado Petroleum Storage Tank Fund will be paid in full by the applicant upon receipt of the reimbursement in accordance with a promissory agreement. o Provide a signed and notarized copy of the agreement. Invoice # Invoice Date Amount Paid Invoice # Invoice Date Amount Paid 14140 6/28/21 $9,980.10 • I further state that there is no relationship or affiliation between myself and the applicant. • I hereby certify that the foregoing information is correct to the best of my knowledge, information and belief. I understand there are severe civil and/or criminal penalties for any false statement or misrepresentation of a material fact, knowing it to be false, or failing to disclose a material fact with the intent to defraud. Signature: Date: Printed Name: Jo n D. Drafts Title: Principal Phone #: 303.825.8117 Company (Payee) Name: I Palmetto Environmental Group Company (Payee) Mailing Address: 4995 York St City: J Denver State: CO ZIP: j 80216 Notary Public Certification Subscribed and sworn to before me inthe county of 0Q n tom/ ,State of this day of -' 2 MICHAEL R CRITCHLEY �-��`j NOTARYPUBLIC Notary Public Printed Name: Signature: G� s 2 My Commission Expires21 Y COMMISSION EXPIRES FEBRUARY 07, 2024 (303) 825-8117 - 4995 York Street o Denver, Colorado 80216 a mail@palmetto-environmental.com W-9 Request for Taxpayer Give Farm to the Form (Rev.May2019) Identification Number and Certification requester or State State of Colorado t?apartment. Do not Substitute ► Go to www.irs.gov/FormW9 for Instructions and the latest Information, send to the IRS. I Name(as shown on your Income tax ieturil), Name is requked on this One; do not leave this line blank: WELD COUNTY GOVERNMENT 2 Business name/dlaregarded entity name, If different (ruin abdvs 3 Check appropriate box for federal tax classification of the person whose name is entered on the 1. Check only one of the 4 Exemptions (codes apply only to following seven boxes. certain entities, not individuals; sea a p :• ` ❑ trrdvldual/sole proprietor or ❑ C Corporation ❑ S Corporation ❑ Partnership ❑ Trust/estate Instructions on page 3): single -member LW Exempt payee code Gt any) 3 . ❑ Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=Partnerahip) ► Note: Check the appropriate box In the line above for the tax classification of the single -member owner. Do not check Exemption from FATCA reporting LLC If the LLC Is classified as a single -member LLC that Is disregarded from the owner unless the owner of the t.LC is another LLC that Is not disregarded from the cwnertor U.S. federal tax purposes. Otherwise, a single -member LLC that code (If any) a. Is disregarded from the owner should check the approptete box for the tax classification of its owner, ❑ Other (see Instructions) ► ❑ Government rAppra•roxccovrteasbd lePredad ee sere v.3J 5 Remittance address (number, street, and apt/suite or PD Box), See Instructions, 1 Procurement address if different (optional) 1150O STREET 8 City, state and ZIP code GREELEY, CO 80631 --- T Contact Hama end small BARBARA CONNOLLY BCONNOLLY@WELDGOV.COM •t1pI_ Taxpayer Identification Number (TIN) -Enter your (iN lithe appropriate -box. The TIN provided must match the name given Oct line Ito avoid Taoclal security backup withholding. For individuals, this Is generally your social security number (SSN). However, for a resident alien, sole proprietor, or disregarded entity, see the Instructions for Part 1, later. For other entities, It Is your employer identification number (E1N). If you do not have a number, sea How to got a 71W, later. or Note; If the account is in more than one name, see the instructions for line 1. Also see What Name and tnpley' rldenti Number To Give the Requester for guidelines on whose number to enter. •17—T—i i - n pens s perjury; certfy that: 1. The number shown on this form is my correct taxpayer identification number (or I em waiting for a number to beIssued to me); and 2.1 am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that lam subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding; and 3. 1 am a U.S. citizen or other U.S. person (defined below); and 4. The FATCA code(s) entered an this form (if any) indicating that I am exempt from FATCA reporting is correct. Certification Instructions. You must cross out item 2 above If you have been notified by the IRS that you are currently subject to backup whhholdhng because you have failed to report all interest and dividends on your tax return. For real estate transactions, Item 2 does not apply. For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments other than Interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the instructions for Part 1l, later. Sign Signature of x1+` Here U.S. person Date- /5Jj - General Instructions • • • Form 1099-DIV (dividends, Including those from stocks or mutual funds) Section references are to the Internal Revenue Code unless otherwise • Form 1099-MISC (various types of income, prizes, awards, or gross noted. proceeds) Future developments: for the latest information abaft developments • Form 1099-B (stock or mutual fund sales and certain other related to Form W-9 and its instructions, such as legislation enacted transactions by brokers) after they were published, go to www.frs.gov1FormW9. s Form 1099-S (proceeds from real estate transactions) Purpose of Form • Form 1099-K (merchant card and third party network transactions) An individual or entity (Form W-9 requester) who is required to fife an • Form 1098 (home mortgage Interest), 1098-E (student loan interest), Information return with the IRS must obtain your correct taxpayer 1098-T (tuition) identification number (flfs. which may be your social security number • Form 1099-C (canceled debt) (SSN), Individual taxpayer identification number (ITIN), adoption • Form 1098 A (acquisition or abandonment of secured property} taxpayer identification number (ft,11N), or employer Identification number (EIN), to report on an information return the amount paid to you, or other Use Form W-9 only If you are a U.S. person (including a resident amount reportable on an Information return. Examples of information alien), to provide your correct TIN. returns include, but are not limited to, the following. If you do not return Form W-9 to the requester with a TIN, you might • Form 1099-INT (interest earned or paid) be subject to backup withholding. See What is backup withholding, later. Cat, No. 10231X Form VIr-9 (Rev. 5-2019) COLORADO PETROLEUM STORAGE TANK FUND Photocopyadditional pages as necessary LISTING OF COSTS Primary Invoice #1 14140 Contractor Name Palmetto Environmental Dates of Work2 xxlxxlxx Xodxx/xx Beginning Ending 417121 516!27 Proof of Payment Invoice Amount $9,880.10 Amount Submitted for Reimbursement $9,980.10 Canceled Check Others Check # Check Amt NOTES: TOTAL SUBMITTED FOR REIMBURSEMENT CONSIDERATION:CONSIDERATION:I $9,980,10 I List ail PRIMARY invoices. If invoice does not clearly identify work performed, add that information to the invoice copy submitted with the appicetion. 2 List invoices in order by the date of work performed (dates) work was actually performed, not the invoice date). 3 if proof of payment is by canceled check, back of canceled check is also required if the dollar amount is not encoded by the bank an the front of the check 4 If proof of payment is by payee affidavit or CPA Cerfiication, use following codes: AFF - Affidavit CPA = CPA Certification of Payment. Use COLE Forms. 6 List only ALLOWABLE costs. If amount requested differs from invoice amount, Idetrtify on the invoice any cost for which reimbursement Is NOT requested. REV 3116/12 DAKOTA DRILLING, INC.. 138O UMATILLA STREET DENVER, COLORADO 80204 (303) 893-2810 Bill To: Palmetto Environmental Group LLC 4995 York Street Denver, CO 80216 **.Net 30 ** AMOUNT DUE 5,502.00 From invoice Date Thank you for your Business l f f Invoice #: Invoice Date: Client PO # Driller Job Location 201336 05/04/2021 14027 Glen Melonas 1113 H St Greeley Sold To: INVOICE Pace Analytical Services, LLC 9608 Loiret Blvd. Pace Analytical Services, LLC 41-1821617 Lenexa, KS 66219 Pace aPhone: (913)599-5665 Analytical Pace Analytical Gulf Coast 45-4027089 www.pacelabs.com Invoice Number: 2160131914 Date: 05/12/2021 Total Amount Due: $540.00 Please Remit To: John Drafts Palmetto Environmental 4995 York Street Denver, CO 80216 303-825-8117 x107 Pace Analytical Services, LLC P.O. Box 684056 Chicago, IL 60695-4056 Client Number/Client ID Purchase Order No Pace Project Mgr Terms** Page 60-506268 / Palmetto Heather Wilson Net 30 Days 1 Client Project: 1113 H STREET Client Name: Palmetto Pace Project No: 60368895 Sample Received: 5/8/2021 Report Sent To: John Drafts, Palmetto Environmental Comments: ANALYTICAL CHARGES Quantity Unit Description Method Matrix Price Total 4 Ea 8260 MSV GRO and BTEX EPA 8260 Solid $65.00 $260.00 4 Ea TPH-DRO EPA8015B Solid $70.00 $280.00 Analytical Subtotal $540.00 Total Number of Charges 8 Total Invoice Amount $540.00 Samples Received for analysis: Lab ID Client Sample ID Received 60368895001 MW -01 @ 5'-7' 5/8/2021 9:15:00 60368895002 MW -02 @ 5'-7' 5/8/2021 9:15:00 60368895003 MW -03 @ 5'-7' 5/8/2021 9:15:00 60368895004 MW -04 @ 5'-7' 5/8/2021 9:15:00 If you have any questions, please contact Heather Wilson at Pace. Phone: 1(913)563-1407 Email: heather. wilson@pacelabs.com Page l of I **1.5% MONTHLY FINANCE CHARGE ASSESSED AFTER 30 DAYS OR TERMS OF CONTRACT. PACE RESERVES THE RIGHT TO SURCHARGE ON CREDIT CARD PAYMENTS BASED ON CARD TYPE AND ZIP CODE. PLEASE REFERENCE THE INVOICE NUMBER ON ALL REMITTANCE ADVICE. AN EQUAL OPPORTUNITY EMPLOYER Please complete and return copy of invoice with your payment. INVOICE TOTAL $540.00 Amount Paid: $ Check No: Customer No: 60-506268 Invoice No: 2160131914 Esther Gesick From: Chris D'Ovidio Sent: Monday, February 7, 2022 3:54 PM To: Esther Gesick Subject: FW: 1113 H St. Reimbursement Applications and Invoices Here is a little more on the process for the reimbursement process Christopher D'Ovidio Accounting Department 1150 O Street Greeley, CO 80632 tel: 970-400-4447 email: cdovidio@co.weld.co.us t 1 r Confidentiality Notice: This electronic transmission and any attached documents or other writings are intended only for the person or entity to which it is addressed and may contain information that is privileged, confidential or otherwise protected from disclosure. If you have received this communication in error, please immediately notify sender by return e-mail and destroy the communication. Any disclosure, copying, distribution or the taking of any action concerning the contents of this communication or any attachments by anyone other than the named recipient is strictly prohibited. From: John Drafts <JDD@palmetto-environmental.com> Sent: Monday, February 7, 2022 2:57 PM To: Chris D'Ovidio <cdovidio@weldgov.com>; David Springer <dspringer@weldgov.com> Subject: RE: 1113 H St. Reimbursement Applications and Invoices ICaution: This email originated from outside of Weld County Government. Do not click or open attachments unless you recognize the sender andknow the content is safe. " Chris, Thank you for facilitating the signature from the Commissioner. Now that we have that, we will submit the original application to the OPS tomorrow. It usually takes them 2-4 months to review and bring the site in front of the reimbursement fund for approval. Once we receive payment for the other invoices, we will submit those applications and ideally the OPS will approve all funds at the same time following the reimbursement hearing. Thanks, John D. Drafts, PG Palmetto Environmental Group, LLC 4995 York Street Denver, Co 80216 303-825-8117 x 107 (o) 303-356-2645 cell From: Chris D'Ovidio <cdovidio@weldgov.com> Sent: Monday, February 7, 2022 2:51 PM To: David Springer <dspringer@weldgov.com>; John Drafts <JDD@palmetto-environmental.com> Subject: FW: 1113 H St. Reimbursement Applications and Invoices Good Afternoon Please see the attached signature sheets signed by Commissioner Scott James. Can you tell me what the expected turn around is on this? Please let me know if there is anything else I can do. Thanks Christopher D'Ovidio Accounting Department 1150 O Street Greeley, CO 80632 tel: 970-400-4447 email: cdovidio@co.weld.co.us Confidentiality Notice: This electronic transmission and any attached documents or other writings are intended only for the person or entity to which it is addressed and may contain information that is privileged, confidential or otherwise protected from disclosure. If you have received this communication in error, please immediately notify sender by return e-mail and destroy the communication. Any disclosure, copying, distribution or the taking of any action concerning the contents of this communication or any attachments by anyone other than the named recipient is strictly prohibited. From: Chris D'Ovidio Sent: Friday, February 4, 2022 4:43 PM To: David Springer <dspringer@weldgov.com>; John Drafts <JDD@palmetto-environmental.com> Subject: RE: 1113 H St. Reimbursement Applications and Invoices Hi John We will have the payments for the invoice out to you on Monday the 8th. I will also have the signature sheets signed on that day as well. Just an item of note the attached request did not have a signature page, so I printed a copy from one of the others. Thanks Christopher D'Ovidio Accounting Department 1150 O Street Greeley, CO 80632 tel: 970-400-4447 email: cdovidio@co.weld.co.us Confidentiality Notice: This electronic transmission and any attached documents or other writings are intended only for the person or entity to which it is addressed and may contain information that is privileged, confidential or otherwise protected from disclosure. If you have received this communication in error, please immediately notify sender by return e-mail and destroy the communication. Any disclosure, copying, distribution or the taking of any action concerning the contents of this communication or any attachments by anyone other than the named recipient is strictly prohibited. From: David Springer <dspringer@weldgov.com> Sent: Thursday, February 3, 2022 4:38 PM To: Chris D'Ovidio <cdovidio@weldgov.com> Cc: John Drafts <JDD@palmetto-environmental.com> Subject: FW: 1113 H St. Reimbursement Applications and Invoices Chris, Can you answer John's question? This is the packet of paperwork I brught up to you the first part of January. David Springer Director, Fleet Services Weld County Government 1399 N. 17th Ave. Greeley, CO 80631 970-400-3513 970-673-5007 cell Confidentiality Notice: This electronic transmission and any attached documents or other writings are intended only for the person or entity to which it is addressed and may contain information that is privileged, confidential or otherwise protected from disclosure. If you have received this communication in error, please immediately notify sender by return e-mail and destroy the communication. Any disclosure, copying, distribution or the taking of any action concerning the contents of this communication or any attachments by anyone other than the named recipient is strictly prohibited. From: John Drafts <JDD@palmetto-environmental.com> Sent: Thursday, February 3, 2022 4:31 PM To: Morgan Tice <mtice@weldgov.com> Cc: David Springer <dspringer@weldgov.com>; Katie Drafts <Katie@ palmetto-environmental.com> Subject: RE: 1113 H St. Reimbursement Applications and Invoices CaUtlon.This ernaji originated fi outside of Weld County Government Do not click links or open attachments unless you recogrize the tide d the conic t•is safe ' Good afternoon, Can you please update me on where we stand with having the signature page signed as well as payment for the invoices attached to the previous email? Thanks, John D. Drafts, PG Palmetto Environmental Group, LLC 4995 York Street Denver, Co 80216 303-825-8117 x 107 (o) 303-356-2645 cell From: John Drafts Sent: Friday, January 7, 2022 9:40 AM To: mtice@weldgov.com Subject: FW: 1113 H St. Reimbursement Applications and Invoices Good Morning, David springer requested I also send you these documents related to the cleanup of the fuel release. Please let me know if you have any questions. Thanks, John D. Drafts, PG Palmetto Environmental Group, LLC 4995 York Street Denver, Co 80216 303-825-8117 x 107 (o) 303-356-2645 cell From: John Drafts Sent: Thursday, January 6, 2022 12:02 PM To: David Springer <dspringer@weldgov.com> Subject: FW: 1113 H St. Reimbursement Applications and Invoices 4 David, It likes like Katie sent these to the admin group? The attachments with the dates are reimbursement applications that the Board Chairman will have to sign (page 4 of each application). The other two attachments labeled invoices are the outstanding invoices that need to be paid. Once we receive the checks and signed signature pages associated with the applications we will get all of this submitted to the OPS for reimbursement. Please let me know if you have any questions. Thanks, John D. Drafts, PG Palmetto Environmental Group, LLC 4995 York Street Denver, Co 80216 303-825-8117 x 107 (o) 303-356-2645 cell From: Katie Drafts <Katie@palmetto-environmental.com> Sent: Thursday, January 6, 2022 11:36 AM To: John Drafts <JDD@palmetto-environmental.com> Subject: FW: 1113 H St. Reimbursement Applications and Invoices From: Katie Drafts Sent: Tuesday, November 16, 2021 2:16 PM To: bconnolly@weldgov.com Subject: 1113 H St. Reimbursement Applications and Invoices Hi Barbara, I've attached several items that need to be passed through the County Board of Commissioners. Palmetto has created 3 invoices and reimbursement applications for the remediation work being performed at 1113 H St. Below is the status of each: Invoice #1— PAID (thank you!) Reimbursement Application 4/7/21— 5/6/21— Needs approval and signature on Page 4 by the Chair — Board of County Commissioners (Aff Proof of Payment has been signed by Palmetto.) Invoice #2 — Both 15040 and 15040Z need to be paid. Reimbursement Application 5/10/21— 6/28/21— Needs approval and signature on Page 4 by the Chair — Board of County Commissioners (Palmetto will sign the Aff Proof of Payment once payment is received.) Invoice #3 — Both 15076 and 15076Z need to be paid. Reimbursement Application 6/30/21— 9/27/21— Needs approval and signature on Page 4 by the Chair — Board of County Commissioners (Palmetto will sign the Aff Proof of Payment once payment is received.) Once payment is received and signature pages are signed and returned, Palmetto will submit all costs over the $10,000 deductible to the Petroleum Storage Tank Fund for reimbursement. Please let me know if you have any questions. Thanks! Katie Drafts Reimbursement Coordinator/Office Manager Palmetto Environmental Group, LLC 4995 York St. Denver, CO 80216 P: 303.825.8117 x.100 www.Palmetto-Environmental.com katie(c�oalmetto-environmental.com PALMETTO ENVIRONMENTAL (.ROUT' LLC COLORADO PETROLEUM STORAGE TANK SUPPLEMENTAL REIMBURSEMENT APPLICATION FUND Short Form S (2017) This form should be used, and can only be used, on Supplemental Reimbursement Applications when the RAP # Applicant has already established eligibility for reimbursement of remediation costs relative to this occurrence. IDLE/OPS Internal Use only The nature of this Supplemental Reimbursement Application is: (Select all that apply] Additional costs not previously reimbursed. X Other (Explain): List RAP # of last application previously filed for this remediation: Applicant's Full ISocial Security # or Federal Legal Name: Weld County Government Tax ID # 84-6000813 Contact Person: Barbara Connolly Phone # 970.400.4445 Fax # Mailing Address: Street: 1150 0 Street Email: bconnolly@weldgov.com City: Greeley State CO Zip 80631 Reimbursement Remit Entity: Mailing Address (if different): Street: State Zip (Email Applicant is (select one): ` Government Site Name: Weld County Fueling Facility Site Address: Street: 1113 H Street City: Greeley State CO Zip 80632 Complete this section only if you want the representative to be the primary contact and copied on all correspondence. Applicant's Name Palmetto Environmental Group Representative Address 4995 York St. (if applicable) Email: mail@palmetto-environmental.com Phone # 303.825.8117 City Denver State CO Zip 80216 IF# 303.534.5049 Total from Listing of Costs, last column: $28,548.36 Less reimbursement from any other source (see #5): NET REIMBURSEMENT REQUEST: $28,548.36 iDates of work covered by this application: From: 5/10/21 To: 6/28/21 For OPS Use Only Facility ID: Type: Date Received by OPS Event ID: Technical Reviewer: Last RAP: Fund Analyst: OPS Revised From Date Revised To Date Amount After Converted Revisions REV 8/4/17 *Prior versions of this application will not be accepted Page 1 of 4 REIMBURSEMENT INFORMATION 1 Will there be additional reimbursement applications for this release? Yes Have any of the costs submitted for reimbursement already been submitted with another reimbursement 2 application? If yes, identify these costs and explain why you are resubmitting these costs: No Do any of the costs submitted for reimbursement cover a time period for which you have already received, or requested reimbursement? If yes, identify these costs and explain why you are resubmitting them: No Except for any contractual relationship established In response to this remediation, is there any relationship - personal, financial, or otherwise - between Applicant and any company or person who performed work for which 4 reimbursement is claimed? If yes, explain: No Has Applicant received, or does Applicant expect to receive, compensation for corrective action costs from ANY source other than the Colorado Petroleum Storage Tank Fund, including lawsuits, settlements, judgments, contributions from other parties? If yes, state amount of other reimbursement $ Identify source of reimbursement, including court case name and number, 5 if applicable: No Note: If there have been any changes to insurance from that submitted with the Original Application, provide updated information with this Application (in the same format as the Original Application) 6 Do any costs claimed for reimbursement represent work performed by the Applicant or Applicant's employees? If No -yes, submit the Affidavits Regarding Work Performed by Applicant. Has the Legal Name, Remit Entity or Address, Mailing Address or Tax Payer Identification Number changed 7 since the submittal of the Original or last Supplemental Reimbursement Application? If so, please submit a W-9 No (scanned signature is acceptable) - see Completing App Instructions tab. g. W-9 - If you answered yes. to. question 7, attach a W-9 to this application and explain any changes here. REV 614117 *Prior versions of this application will not be accepted Page 2 of 4 By submitting this application, the Applicant affirms, certifies and agrees as follows: 1. The Applicant certifies, under penalty of law, that Applicant lathe appropriate person to request reimbursement, and that this document and all attachments were prepared under Applicant's direction or supervision In accordance with a system designed to assure that qualified personnel property gathered and evaluated the Information submitted. 2. The Applicant Is the Owner/Operator or duly authorized agent of the Owner/Operator responsible for this Site. The Applicant Is end shall be responsible for assuring compliance with all applicable State and federal regulations. 3. The information submitted by the Applicant, to the best of Applicant's knowledge and belief, Is true, accurate and complete. Applicant understands that this Application will be submitted by the Colorado Department of Labor and Employment (COLE or State) for consideration by the Petroleum Storage Tank Committee (Committee). Upon demand by the Committee, Applicant agrees to return the entire award Applicant may receive or any other amount the Committee considers appropriate If (a) Applicant misrepresented or omitted any fact, either in writing or orally, relevant to the determinations made by the Committee or the COLE; or (b) Applicant falls to complete, to the Committee's or the COLE's satisfaction, the corrective action. 4. The Applicant shall not be entitled to obtain any other reimbursement from any source other than the State for the same costs or work reimbursed by the State. Any reimbursement the Applicant receives or is entitled to receive, including insurance proceeds, is and shall be the property of the State of Colorado to the extent of payment(s) made to the Applicant by the State from the Petroleum Storage Tank Fund. Upon receipt of any such reimbursement from a source other than the State, Applicant shall immediately report and pay such reimbursement to the State. 5. To the extent payment is made from the Petroleum Storage Tank Fund, the Applicant hereby assigns to the State of Colorado any rights the Applicant may have which may allow the Applicant to seek and obtain recovery from any other entity for the costs or work reimbursed by the State, including the right to recover from Insurance companies. 6. The Applicant shall not submit any further claims for reimbursement from the State for the Site(s) and work Identified In this Application, other than an amendment to the Application or protest of the Fund Payment Report, if any, for work not heretofore reimbursed. 7. Applicant shall indemnify, save, and hold harmless the State, its employees and agents, and the Committee against any and all claims, damages, liability and court awards Including costs, expenses, and attorney fees and related costs, Incurred as a result of any act, omission or misrepresentation by the Applicant, or Its employees, agents, subcontractors, or assignees pursuant to the terms of this Application. As to governmental entity Applicants, no term or condition of this Application shall be construed or Interpreted as a waiver, express or Implied, of any of the Immunities, rights, benefits, protection, or other provisions, of the Colorado Governmental Immunity Act, CRS 24.10- 101 at seq., or the Federal Tort Claims Act, 28 U.S.C. 2671 at seq., as applicable, as now or hereafter amended. 8. In addition to any other legal rights the State of Colorado may have, the State shall have audit and on -site inspection rights for 3 years after payment 9. The remedlation services and supplies far which expenses are listed In this Application were performed and/or purchased at the most reasonable rates available for compliance. 10. The Applicant shall provide all formal or informal environmental assessment Information to any future owner upon request. 11. In the event the Applicant breaches any of the terms, conditions or requirements of this Application, the State of Colorado, In addition to any other remedies, at law or equity, shall be entitled to Immediate repayment on demand of all amounts paid to the Applicant; and in the event that the State is required to take legal action to enforce any of the provisions contained herein, the State shall be entitled, In addition to damages, to its costs and reasonable attorney fees and related expenses Incurred in connection with such enforcement IL At all times dining the performance of this remediation, the Applicant shall strictly adhere to all applicable federal and State haws, rules and regulations that have been or may hereafter be established, Including without limitation 42 U.S.C. 6991 and CR5 It -20.5.101, et seq., and associated regulations. 13. The State may allocate more or fees funds to the remedlation described in this Application -than the amount requested by the Applicant. Once the reimbursement request is approved, the State will issue a Fund Payment Report, substantially In the form of Exhibit B, documenting the amount that will be processed and paid. 14. The Committee has the authority and the right to designate funds be paid to Applicants on pro -rata basis when the Petroleum Storage Tank Fund balance prevents payment in full, pursuant to CRS 8-20.5-206(e)(2). 15. Each additional request by Applicant for reimbursement from the Petroleum Storage Tank Fund must be submitted on a new supplemental application. Any additional payment by the State shall be conditioned upon the Issuance by the Committee of a new Fund Payment Report for payment. 16. Pursuant to 7 CCR 1101.14, Article 8, the Applicant may file a protest of the Fund Payment Report If the Applicant disputes a decision by the Committee, as stated on the Fund Payment Report. The Applicant may petition the Committee to review its decision. A Protest must be submitted within 60 days of the date of the Fund Payment Report. See 7 CCR 1101-14, 8-6. The Applicant shall use the form of Protest of Fund Payment Report provided by the Division of Oil and Public Safety of the Colorado Department of Labor and Employment. 17. The maximum amount to be paid by the State, if any, in connection with this reimbursement request shall be authorized by the Committee in the Fund Payment Report. 18. The payment by the State and acceptance by the Applicant of any reimbursement amounts requested under this Application shall be deemed to be good and sufficient consideration for the promises, certifications and affirmations made by Applicant in this Application. Revised 814117 -prior versions ci this application eii not be accepted Page S of 4 signatory Page Weld County Government Legal Name of Applicant 84-6000813 or or all 1ao *a Date Scott K. James, Chair - Board of County Commissioners Print Name a Title of Authorized Officer Complete if this Is a replacement signatory page RAP# FACILITY IDN EMAIL TO: Sdte,,PSTRelmbursementJoos®state.co.us if you have any questions please consult the OPS website and/or contact OPS at (303) 318-8510. OPS website: htto:Jlwww.cotorado.govloos REV 814117 Tdor verslons of This appllosUon will not be accepted Page 4 of 4 PALMETTO ... a' s ME 'TAL GROUP LLC Affidavit: Proof of Payment (Revised 1/5/2016) This form should be used when an applicant submits an affidavit as proof of payment for costs claimed for reimbursement. This form is not required if copies of canceled checks or other bank confirmations of payment are provided. Please note the following requirements. • This form must be reproduced on the company letterhead of the payee (not the applicant's letterhead). o Affidavits that are not on the payee's letterhead will not be accepted. • This form must be signed by the payee, not the applicant. • Use a separate affidavit for each contractor. • Do not use this form if there is any affiliation or relationship between the applicant and the payee. More information is available in Section 8-2 (b) (2) of the l- r Stra< Y,a Tani; Reaula_ions. Applicant Information Applicant Name: Weld County Government Site Name: Weld County Fueling Facilfty Site Address: 1113 H Street City: Greeley State: f CO j ZIP: f 80632 Payee Information and Certification Check the following, as appropriate. 0 1, being first duly sworn upon oath and being of lawful age, state that the following invoices relative to the referenced application for reimbursement from the Colorado Petroleum Storage Tank Fund have been paid in full by the applicant. ❑ I, being first duly sworn upon oath and being of lawful age, state that the following invoices relative to the referenced application for reimbursement from the Colorado Petroleum Storage Tank Fund will be paid in full by the applicant upon receipt of the reimbursement in accordance with a promissory agreement. o Provide a signed and notarized copy of the agreement. Invoice # Invoice Date Amount Paid Invoice # Invoice Date Amount Paid 15040 11/1/21 $28,265.90 15040Z 11/1/21 $282.46 • I further state that there is no relationship or affiliation between myself and the applicant. • I hereby certify that the foregoing information is correct to the best of my knowledge, information and belief. I understand there are severe civil and/or criminal penalties for any false statement or misrepresentation of a material fact, knowing it to be false, or failing to disclose a material fact with the intent to defraud. Signature: Date: Printed Name: John D. Drafts J Title: Principal Phone #: 303.825.8117 Company (Payee) Name: Palmetto Environmental Group Company (Payee) Mailing Address: 4995 York St City: I Denver State: CO I ZIP: I 80216 Notary Public Certification Subscribed and sworn to before me in the county of ,State of this day of Notary Public Printed Name: Signature: My Commission Expires: (303) 825-8117 e 4995 York Street a Denver, Colorado 80216°mail@palmetto-environmental.com COLORADO PETROLEUM STORAGE TANK FUND Photocopy additional pages as necessary LISTING OF COSTS Primary Invoice #1 Contractor Name Dates of Work2 xxlxxlxx xxlxxlxx Beginning Ending Proof of Payment Invoice Amount Amount Submitted for Reimbursements Canceled Check3 Other4 Check # Check Amt 15040 Palmetto 5110/21 6/28/21 AFF $28,265.90 $28,265.90 15040Z Palmetto 5/10/21 6/28/21 AFF $282.46 $282.46 TOTAL SUBMITTED FOR REIMBURSEMENT CONSIDERATION: $28,548.36 I List all PRIMARY invoices. If invoice does not clearly identify work performed, add that information to the invoice copy submitted with the application. 2 List invoices in order by the date of work performed. 3 if proof of payment is by canceled check, back of canceled check is also required If the dollar amount is not encoded by the bank on the front of the check. 4 If proof of payment is by payee affidavit or CPA Certification, use following codes: AFF = Affidavit. CPA = CPA Certification of Payment. Use CDLE Forms. 8 List only ALLOWABLE costs. If amount requested differs from invoice amount, identify on the invoice any cost for which reimbursement is NOT requested. INVOICE BILL TO Palmetto Environmental 4995 York Street Denver, CO 80216 PROJECT NAME 1113 H Street Please let me know If you have any questions, or if I can help with BALANCE DUE $560.09 anything at all. W Regards, Nestle Origins Laboratory, Inc. 1725 West Elk Place Denver, CO 80211 US (303)433-1322 jdoyle@originslab.com PROJECT NUMBER 14027 INVOICE # Y105283 DATE 05/2112021 # OF SAMPLES 4 GW INVOICE Page 1 of 2 WASTE MANAGEMENT Visit wm.com to sign up for paperless billing or pay your invoices. Visit wmsolutions.com to manage your waste streams and access additional disposal documentation. 0 Customer Service: (720)977-2102 Customer ID: Customer Name: Service Period: Invoice Date: Invoice Number: Jun 30, 2021 If full payment of the invoiced amount is not received withki your contractual terms, you may be charged a monthly late charge of 2.5% of the unpaid amount, with a mnimum rrgntHy charge of $5, or such late charge allowed underapplcable law, regulation or contract. 1-62687-24Q-04 PALMETTO ENVIRONMENTAL 05/01/21-05/31,/21 06/01/2021 0033007-1528-5 $50.00 If payment is received after 06/30/2021: $ 55.00 Previous Balance Payments Adjustments Current Invoice Total Account Charges Balance Due Details for Service Location: Customer ID: 1-62687,-24004 Palmetto Environmental, 4995 York Street, Denver CO 80216-2245 Description Date Ticket Quantity Unit of Rate Amount _ Measure Vehicle#: NONE 05/21/21 171543 0.00 PROFILE PROCESSING FEE 1.00 ECH 50.00 50.00 Profile # 133099CO 0.00 Generator WELD COUNTY GOVERNMENT 0.00 Ticket Total 50.00 Total Current Charges 50-00 x ---------------------------------Please detach and d the lower portion with payment ---(nocashorstaplas)---------------------------- WASTE MAMAOEMENT CONSERVATION SERVICES, INC. PO BOX 43350 PHOENIX, AZ 65080 (72O)977 -21O2 (303) 644-4335 TICKET COPIES 152800100162687240©400033D07D000060500600000005606 3 0n31009Q1A30.425 "AUTO T907154 30216-224595-coo-P.I040-H iaaosc9a 1l'tId[nIliIriir[rriiil'IIl[IlrrlliII'III'II`ItII".11111liI'll liilliillf'fl't'llllll"III>♦1'['Illilll"IIlI`IlIrllrll`ltlll"ll WM CORPORATE SERVICES, INC. PALMETTO ENVIRONMENTAL Remit To: AS PAYMENT AGENT 4995 YORK STREET 'x PO BOX 7400 DENVER CO 80216-2245 PASADENA, CA 91109-7400 0 0 8 THINK GREEN: a�t>:reloa WASTE MANAGEMENT Visit wm.com to sign up for paperless billing or pay your invoices. visit wmsalutions.corn to manage your waste streams' and access addirional disposai documentation. Customer Service: (72O)977-2102 + 50.00 (50.00) INVOICE Customer ID: Customer Name: Seance Period Invoice Oate Invoice Number: Jul 30, 2021 it If NO pa'ment of the irrvr_iced arncunt is rut recer ed within ycur contractual terms, you may be eyed a I rrcntHy late ;nary of 25%> of ti -e urpaid amount, with a rririrr-um rrc ntl y +ar5e of $5, or such lace charge allowed under applbhe law, r eulaticn or ccrtrect. Page 1 of 3 1-62687-24004 PALMETTO ENVIRONMENTAL 06/01/21-06/30/21 07/01/2021 0033089-1528-3 $2,1'16.80 If payment is received after 07/30/2021: $ 2,148.55 Cl�terrt I�ntatce 2,116.80 Details for Service Location: Customer ID: 1-62687-24004 Palmetto Environmental, 4995 York Street, Denver CO 80216-2245 Unit of Description Date Ticket Quantity Rate ( Amount •Measure Cont. Sod - Perroleurn s. _:1 1':5.!00 o • ^.u1 Ha'-Jub';a� �c'_' R scooi ;e r rr' . _ �_ a 5-� Profile 4 1255-5OO i((/ '� a oo v c,zrat;;r E- -t^<.1`iano-,��i;'f f 'i= ,k.�r.- �..i Vlarifest#:101v3s3 C4— Ca, 1` 0.00 c!e#. L+i=T GATE 05'J'71 1715-/l ...JU Lint. Soil- P-atraieum 3.00 E0H -i 00.00 __- ----------------------- ---------Pieasedetacharid sand the lower portion with payment --- (no cash orstaples) ----------------------------- 0 'NA3TE MA,vA1EMENT 07/01/2021 ` 0033!039-1523-3 1-62687-24004 Z3M5ERvT[Orl SEP,I0E rri: Payment Terms Total Due Amount LS?80000162687240104017!733039000010�],L6,3000000211680 1, ll II ihuIIII,IIhI„I,II[11Iu1„I1111hIi1h11 1lll,hlllllilfiii Ilt lIlil{nlll,tllI' ii liiIIII'lI I WM CORPORATE SERVICES. INC. PALMETTO ENVIRONMENTAL - AS PAYMENT AGENT 4995 YORK STREET PO BOX 7400 DENVER CO 302l5-2243 `+ PASADENA. CA 31 109-7400 T1d1MV c:� a Page 2or3 - 11 . ` Details for Service Location: Customer ID: 1-62687-240O4 Palmetto Environmental, 4995 York Street, Denver CO 80216-2245 i Description Ha?-Sub;:ance Respen;e Fee Drum Promo t 133099CO I 33036 Ticket Total ',a1i:'54: LIFT GATE Gent. Snil - Petroleum Date Ticket Quantity I i 06/01/21; 171640 Unit of I Rate ! Amount Measure 9.00 ; ECH D.D. '300 0 00 500.45 0.00 100.00 900.00 iy.i taji)iyt.1Ij i - ,r— Automatic Payment . - . States the date payment is due to Wasto ( ., r r a-� rr- ' , r Management. Anytheuj beyond that date n;iy ' -'- , %' " "'-' V: it wm.Com 0 e'car addit,onai - harges. your Total Due s the _ . August 19, 2017 Si 24.73 total amount Of _ur _nl rhar.j ind 1ny —_, Pay Through Your Financial Institution "' '-' .. pr' _.lass t.ar] b. thin', canib. _ 1 , Al .. t-�r:- r a ,,.,., +.I .. nil a, 1_r, ,.r .. ___, r , ., .,, •r It: , '.� _ .. _, Prev,rxn balance s the brat toe moll )Our , . _, previous mvoica. 'Ne subtract illy Payments One Time Payment - -- -- ----- - -- Received/Adjustments and aid furl .t 1 ,r i� r r ,r , t . , ...; a,u ,','.trte.' ,+, + y+ _ ] z,•° Current Chwges from tilbd ls hf g '.j'e to i 'i' . ;r a h,c :, u., .let ,,,: ., , r .... e±s» qet a Total Due on !hs imvoice. Ifyau ha.,.� - ----- not paid ail or a portion Of your Hrevalns Pay by Phone _ , ^ ' - ;. bdl inc e, pitaso pay th-• an i Total Due t� t n Sir,• •.harge ar r•r , c Nail it -� . - Su, ace'0 at,sr J'ra k. rho fjrI on=er rhdr S ar this n401f? .:T". Automatic Payments -' Don't worrj' about f 1i5s!(1j b':lt5 or payment;. 1/:J!'j} .ritl OPa j, y.'.0 can 52t it once and at `i5 do the rest, et ;rated by i/iii-lil"� 'v'if7'•.c07n _OO3' •w s ,ru.•yrLJ i .r n.,u nr,....... u,; ^n. hu pd , '.yam,.• .h.0 k• • , r -a ur ,.,nr .r •,. h: -I n.-.1 !,, ._. r- i„r p .,Jl'•• ,,. •, ,.'I m ,,a,, nra .0 ,m ' p,.,Ii „ w ar<uadn uw ann lrnnrt -0b: gpdu rile inert law Fl - CHECK HERETO CHANGE CONTACT INFO .-'.t'7' - '', —rt 1'.' __ 3' -' InJ,y, et a :a: .n. ace - ..- 1!t r. r'ill 1 vr�nc ,„fl., , :' , ,,, ,,,.,,,,.,,,,,,I INVOICE Page 1 of 2 ID WASTE MANAGEMENT Visit wm.com To setup your mine profile, sign up forpapless statements, manage your account, view holiday sd .edules, payyourinvoice or schedule a pickup 0 Customer Service; (720)977-2102 Customer ID: Customer Name: Service Period: Invoice Date: Invoice Number: Jul 30, 2021 If full payment of the invoiced amount is not received within your contractual terms, you may be charged a mmthly late charge of 2.5% of the unpaid amount, wrath a minimum mentfy charge of $5, or such late charge allowed under appiceble law, regulation cc contract. 16-81940-83002 PALMETTO ENVIROMENTAL 06/01/21-06/30/21 07/01/2021 0$14348-28O3-4 )r�reurnrEis Balance . Payments Adjustments Current Invoice TotaEAccourtt Charges. Balance Due �k�,• -�r yr rf; 3rhJh 9 ��i,.-. 'il %-1 1fdt .+ s r ,u.a �.. .,�'zxr �g ,Cs1r`�p�, . - "- .<J ' 4>i4 #� .SS:� is �S" :i4 .b`�iT �wT�..n .,,�+.,,h, 4 .rq _ ']fn$`,H)'• }r, `s. _ r+- err a yJ _ _ Details for Service Location: Customer ID: 16-81940-83002 Palmetto Enviro 4995 York St, 4995 York St, Denver CO 80216 2245 - —__._.-.- Description unit of Description J Date Ticket Quantity Rate measure1 Amount _______________ Vehicle#: 674293 06/01/21 1 155090 0.00 MILK RUNT DRUMS MAXIMUM - I PS 1.0000 DRM 260.0000 260.00 Fuel charge ES 1.0000 1 Flat , 41.2600 41.26 Manifesto: 10108493, 10108496, 10108497 l 0.00 Ticket Tota 41 - u l ' £sty's [ 301.26 qoo ME :t:t4_ Total Current Charges 301.26 - --------------------------------Pleasedetachandsend the lower portion with payment - -- (nocashorstapies)-•---------------------------. WN wASTe MANAGNMeNT WASTE MANAGEMENT OF COLORADO. INC. t 1355 WELD COUNT/ P059 KEEL IE�BOR6. CO ;306-t3 0201 977-2101 Total Due by 07/30/2021 If Received ii*.-er 07/30/2021 '6301.26 $30626 28Q30OU168194083QQ20081,43480000003012600000030126 2 ;vtv:.1 n till .-I:; \,_,r7 13. s: to ,-,I:+-2;.;.0 -l' !t•it II'llsllnllll4llrlrlll'IIIIIlnIIIIIIllIlI+IIII+"IIIIIIII'II 'I"IIIIIIIIII�++I.�II,II11e++III'll'll'i'lul °II'I'IIIIII'Ilrl 11VM CORPORATE SERVICES, INC. PALMETTO ENVIROMENTAL 2er7It r'. AS PAYMENT AGENT 4995 YORK ST �� PO BOX 7400 DENVER CO 60216-224:1 PASADENA, CA 91 109-7400 •vi - THINK GREEN.' kv 2161raF n+ J 3 J WASTE MANAGEMENT NON HAZARDOUS MANIFEST NON -HAZARDOUS MANIFEST 1. Generator's US EPA ID No. Manifest Doc No. 2. Page 1 of 3. Ge r' s Mailing Address: I I j Ii S F � � -C) Generator's Site Address (IfdiNerentEhan mailing): A. Manifest Number WMNA 10108496 B. State Generator's ID Phone . Ge�C 5. Transporter 1 Company Name 6. US EPA ID Number C. State Transporter's ID D. Transporter's Phone 7. Transporter 2 Company Name 8. US EPA ID Number E. State Transporter's ID F. Transporter's Phone 9. Designated Facility Name and Site Address 10. US EPA ID Number G. State Facility ID H. State Facility Phone 303-644-4335 11. Description of Waste Materials 12. Containers . 13Total Quantity 14. Unit Wt./Vol. MiMisc.Comments No. Type E N a. t%� �" c '' 1 h ci1tdS S S') cc N E WM Profile # VY0r1CCQ R b. A T O WM Profile # R C. WM Profile # REGULATORY AGENCY: Colorado Department of Public Health and Environment 4300 Cherry Creek Drive South Denver, CO 80222-1530 J. Additional Descriptions for Materials Listed Above K. Disposal Location ACCOUNT #: CUST NAME: Cell Level Grid 15. Special Handling Instructions and Additional Information Purchase Order# 0 7 EMERGENCY CONTACT/ PHONE NO.: 1-800-424-9300 24HR TOLL FREE 16. GENERATOR'S CERTIFICATE: I hereby certify that the above -described materials are not hazardous wastes as defined by CFR Part 261 or any applicable state law, have been fully and accurately described, classified and packaged and are in proper condition for transportation according to applicable regulations. Printed Name Signature "On behalf of' Month Day Year T 17. Transporter 1 Acknowledgement of Receipt of Materials A Printed Name Signature Month Day Year N 0 18. Transporter 2 Acknowledgement of Receipt of Materials R T Printed Name Signature Month Day Year E R 19. Certificate of Final Treatment/Disposal F A I certify, on behalf of the above listed treatment facility, that to the best of my knowledge, the above -described waste was managed in compliance with all applicable laws, regulations, permits and licenses on the dates listed above. I 20. Facility Owner or Operator: Certification of receipt of non -hazardous materials covered by this manifest. T Y Printed Name Signature Month Day Year White- TREATMENT, STORAGE, DISPOSAL FACILITY COPY Blue- GENERATOR #2 COPY Yellow- GENERATOR #1 COPY Pink- FACILITY USE ONLY Gold -TRANSPORTER #1 COPY Petro Waste Solutions LLC 4995 York Street, Unit B Denver, CO 80216-2245 USA Voice: 303-825-8117 Fax: 303-534-5049 Palmetto Environmental Group LLC 4995 York Street Denver, CO 80216 Palmetto INVOICE invoice Number: 314 Invoice Date: Jun 14, 2021 Page: 1 Duplicate Weld County Fueling Facility 1113 H Street Greeley, CO 80632 Net 30 Hand Deliver 6/3/21 7114121 PETRO WASTE SOLUTIONS Time And Materials Sheet Weld Co. Government Job Name: 1113 H St Greeley, CO 80631 Description of Work: EFR Water Removal Date: 6/3/21 Reimbursment. Total Item Rate Unit Amount Codes Mileage Travel Time On -Site Time Misc. Field Supplies 3 75 75 25 2.75 80 80 Miles Hours Hours Da Miles Hours Hours 125 9.4 5.5 5.5 12.1 9.4 13.99 13.99 $375.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Mileage DOT Truck Travel Time On -Site Time Vacuum Trailer 110 0.6 1,300.00 55 7S Hours Gallons Day Drum each 6.5 229 1 13.99 14.3 14.2 14.2 14.2 14.2 $715.00 $137.40 $0.00 $0.00 $75.00 $0.00 $0.00 Water Disposal AS/SVE Pilot Test Skid 55 Gallon Waste Oil Drum Manifest Fee $0.00 $0.00 $0.00 $0.00 Total $1302. Waste Manifest #1584 EID #14027 Removed 229 gallons C PETROWASTE --- SOLUTIONS NON -HAZARDOUS WASTE MANIFEST 1584 1. Generator's US EPA ID Numb-, Manifest Document Number 2. Page I of 3. Generator's Name and MailingAd,tl�e`ss \�Vc°i�K }cY 5. Generating Location (if different) j , 1� �g /t " J � 1V l90 �CRit1�('c `� 39Sir ± 4. Phone ( ) 6. Phone ( ) 7. Tran orter #1 Company Name 8. US EPA ID Number 9. Transporter #1's Phone 10. Transporter #2 Company Name 11. US EPA ID Number 12. Transporter #2's Phone 13. Designated T/S/D Facility Name and Site Address 14. US EPA ID Number 15. Facility's Phone Petro Waste Solutions CO52329-10798 (303) 356-2645 4995 York Street, Suite B Denver, CO 80216 16. Waste Shipping Name and Description J l Q 1, + �` Ex, C (ue((,L 17. 18. Containers 19. Total Quantity 0. Unit Wt/vol e tJt./ No. Type a. Unleaded Gasoline Contaminated Water ,-y 7 Gallons 0 b. Diesel Contaminated Water Gallons W z W C. d. 21. Additional Descriptions for Materials Listed Above 22. Special Handling Instructions and Additional Information 23. GENERATOR'S CERTIFICATION: I certify the materials described on this manifest are not subject to federal regulations for reporting proper disposal of Hazardous Waste. Printedfryped Name I Signature Month Day Year a k n LO J fr 24. Transporter 1: Acknowledge ent of Receipt of Materials W t Printed/Typed Name q G/f ��'"I`_ Signature Month Da Year O / ! 0) 25. Transporter #2: Acknowledgement of eceipt of Materials z < Printedfryped Name Signature Month Day Year 26. Discrepancy Indication Space >- I — ..t 0 27. Facility Owner or Operator: Certification of receipt of waste materials covered by this manifest (except as noted in Item 19) N NHWM 06/0 Printed/Typed Name Signature Month I Day IY,ear ORIGINAL-ORG(NALRETLRN TO GE ER TO aceAnalytical www.pacelabs.com Sold To: John Drafts Palmetto Environmental 4995 York Street Denver, CO 80216 303-825-8117 x107 INVOICE Pace Analytical Services, LLC 9608 Loiret Blvd. Pace Analytical Services, LLC 41-1821617 Lenexa, KS 66219 Pace Analytical National 62-0814289 Phone: (913)599-5665 Pace Analytical Gulf Coast 45-4027089 Invoice Number: 2160134625 Date: 06/17/2021 Total Amount Due: $2,970.00 Please Remit To: Pace Analytical Services, LLC P.O. Box 684056 Chicago, IL 60695-4056 Client Number/Client ID Purchase Order No Pace Project Mgt Terms" Page 60-5062681 Palmetto Heather Wilson Net 30 Days 1 Client Project: 1113 H ST. Client Name: Palmetto Pace Project No: 60372018 Sample Received: 6/12/2021 Report Sent To: John Drafts, Palmetto Environmental Comments: ANALYTICAL CHARGES Quantity Unit Description Method Matrix Price Total 11 Ea 80158 TPH-DRO EPA 8015B Water $70.00 $770.00 3 Ea 8260 MSV GRO and BTEX EPA 5035A/8260 Solid $65.00 $195.00 8 Ea 8260 MSV GRO and BTEX EPA 8260 Solid $65.00 $520.00 11 Ea 8260 MSV GRO, BTEX, & MTBE EPA 8260 Water $65.00 $715.00 3 Ea Hold acode Solid $0.00 $0.00 11 Ea TPH-DRO EPA 80158 Solid $70.00 $770.00 Total Number of Charges 47 Samples Received for analysis: Lab ID --Client Sam Ip a ID Received 60372018001 PH -1A 6112/20218:25:00 60372018002 PH -2 6/12/20218:25:00 60372018003 PH -3 6/1212021 8:25:00 60372018004 PH -4 6112/2021 8:25:00 , 60372018005 PH -5 6/12/20218:25:00 60372018006 PH -6 6/12/20218:25:001 60372018007 PH -7 6/12/2021 8:25:00 60372018008 PH -8 6/12/20218:25:00 i Analytical Subtotal $2,970.00 Total Invoice Amount $2,970.00 Page 1 of 2 1.5% MONTHLY FINANCE CHARGE ASSESSED AFTER 30 DAYS OR TERMS OF CONTRACT. PACE RESERVES THE RIGHT TO SURCHARGE ON CREDIT CARD PAYMENTS BASED ON CARD TYPE AND ZIP CODE. PLEASE REFERENCE THE INVOICE NUMBER ON ALL REMITTANCE ADVICE. AN EQUAL OPPORTUNITY EMPLOYER Please complete and return copy of invoice with your payment. INVOICE TOTAL $2,970.00 Amount Paid: $ Check No: Customer No: 60-506268 Invoice No: 2160134625 �0I It 12.1 -E(ts aceAnalytical www.pacelabs.com Sold To: John Drafts Palmetto Environmental 4995 York Street Denver, CO 80216 303-825-8117 x107 II N VO I C E Pace Analytical Services, LLC 9608 Loiret Blvd. Pace Analytical Services, LLC 41-1821617 Lenexa, KS 66219 Pace Analytical National 62-0814289 Phone: (913)599-5665 Pace Analytical Gulf Coast 45-4027089 Invoice Number: 2160134625 Date: 06/17/2021 Total Amount Due: $2,970.00 Please Remit To: Pace Analytical Services, LLC P.O. Box 684056 Chicago, IL 60695-4056 Client Number/Clint ID Purchase Order No Pace Project Mgr Terms*' Page 60-506268 / Palmetto Heather Wilson Net 30 Days 2 Client Project: 1113 H ST. Client Name: Palmetto Pace Project No: 60372018 Sample Received: 6/12/2021 Report Sent To: John Drafts, Palmetto Environmental Comments: Samples Received for analysis: Lab ID Client Sample ID Received 60372018009 PH -9 6/12/2021 8:25:00 60372018010 PH -10 6/12/20218:25:00 60372018011 PH -11 6/12120218:25:00 60372018012 PH -1A@2.5' 6/12/20218:25:00 60372018013 PH -2 @ 2.0' 6/12/2021 8:25:00 60372018014 PH -3 @ 1.5' 6/12/2021 8:25:00 60372018015 PH -4 @1.0' 6/12/2021 8:25:00 • '' 60372018016 PH -5 @ 1.0' 6/12120218:25:00 60372018017 PH -6 @ 1.0' 6/12/2021 8:25:00 L 60372018018 PH -7 @ 1.0' 6/12/2021 8:25:00 60372018019 PH -8 @ 1.0' 6/12/2021 8:25:00 60372018020 PH -9 @ 4.0' 6/12/2021 8:25:00 60372018021 PH -10 @ 1.0' 6/12/2021 8:25:00 60372018022 PH -11 @ 1.0' 6/12/2021 8:25:00 60372018023 PH -6 @ 4.0' 6/12/2021 8:25:00 60372018024 PH -7 @ 4.5' 6/12/2021 8:25:00 , 60372018025 PH -8 @4' 6/12/2021 8:25:00 if you have any questions, please contact Heather Wilson at Pace. Phone: 1(913)563-1407 Email: heather.wilson@pacelabs.com Page 2 of 2 '1.5% MONTHLY FINANCE CHARGE ASSESSED AFTER 30 DAYS OR TERMS OF CONTRACT. PACE RESERVES THE RIGHT TO SURCHARGE ON CREDIT CARD PAYMENTS BASED ON CARD TYPE AND ZIP CODE. PLEASE REFERENCE THE INVOICE NUMBER ON ALL REMITTANCE ADVICE. AN EQUAL OPPORTUNITY EMPLOYER DAKOTA DRILLING, INC. 1380 UMATILLA STREET DENVER, COLORADO 80204 (303) 893-2810 Bill To: Palmetto Environmental Group LLC 4995 York Street Denver, CO 80216 Invoice #: Invoice Date Client PO # Driller Job Location 201467 06/08/2021 14027 Jared Gilden 1113 H street Greeley QUANTITY ITEM NO. DESCRIPTION PRICE AMOUNT 11 540 Potholing/Coring _ Utility Clearance 255.00 2,805.00 280 525 Potholer Mobe/Demobe 3.00 840.00 55 570 Temp Wells 0.09 4.95 9 340 55 Gal Drum DOT 17H 55.00 495.00 11 96 1" x 5' Screen 15.00 165.00 19 265 Silica Sand (10-20-50) 10.00 190.00 24 330 Bentonite Chips 9.00 216.00 1 290 Sackrete/Concrete Mix 6.00 6.00 1 300 Asphalt Patch 20.00 20.00 Billing Questions: REMITTANCE ADDRESS Ph. 303-893-2811 1380 Umatilla St, Denver CO Fx. 303-893-2808 80204 Federal Tax ID # 84-361-7658 Net 30 Thank you for your Business!!! Frorn Invoice Date Sub Total Amount Applied AMOUNT DUE 4,741.95 aceAnalytical www.pacelabs.com (/72' Sold To: John Drafts Palmetto Environmental 4995 York Street Denver, CO 80216 303-825-8117 x107 ' y/O' Pace Analytical Services, LLC 9608 Loiret Blvd. Pace Analytical Services, LLC 41-1821617 Lenexa, KS 66219 Pace Analytical National 62-0814289 Phone: (913)599-5665 Pace Analytical Gulf Coast 45-4027089 Invoice Number: 2160134986 Date: 06/22/2021 Total Amount Due: $565.00 Please Remit To: Pace Analytical Services, LLC P.O. Box 684056 Chicago, IL 60695-4056 Cifent:Number/Client ID Purchase Order No Pace Project Mgr Terms*' Page 60-506268 / Palmetto Heather Wilson Net 30 Days 1 Client Project: 1113 H ST. Client Name: Palmetto Pace Project No: 60372018 Sample Received: 6/12/2021 Report Sent To: John Drafts, Palmetto Environmental Comments: ANALYTICAL CHARGES Quantity Unit Description Method Matrix Price Total 1 Ea 8260 MSV GRO and BTEX EPA 5035AI8260 Solid $65.00 $65.00 2 Ea 8260 MSV GRO and BTEX EPA 8260 Solid $65.00 $130.00 1 Ea 8270 MSSV PAH by SIM EPA 8270 by SIM Solid $160.00 $160.00 3 Ea TPH-DRO EPA 8015B Solid $70.00 $210.00 Analytical Subtotal $565.00 Total Number of Charges 7 Total Invoice Amount $565.00 Samples Received for analysis: Lab ID Client Sample ID Received 60372018017 PH -6 @ 1.0' 6/12/2021 8:25:00 60372018023 PH -6 @4.0' 6/12/2021 8:25:00 60372018024 PH -7 @ 4.5' 6/12/2021 8:25:00 60372018025 PH -8 @ 4' 6/12/2021 8:25:00 If you have any questions, please contact Heather Wilson at Pace. Phone: 1(913)563-1407 Email: heather.wilson@pacelabs.com Page 1 of I **1.5% MONTHLY FINANCE CHARGE ASSESSED AFTER 30 DAYS OR TERMS OF CONTRACT. PACE RESERVES THE RIGHT TO SURCHARGE ON CREDIT CARD PAYMENTS BASED ON CARD TYPE AND ZIP CODE. PLEASE REFERENCE THE INVOICE NUMBER ON ALL REMITTANCE ADVICE. AN EQUAL OPPORTUNITY EMPLOYER Please complete and return copy of invoice with your payment. INVOICE TOTAL $565.00 Amount Paid: $ Check No: Customer No: 60-506268 Invoice No: 2160134986 Visit wm.corn to sign up for paperless biiling or your invoices. Visit wmsolutions,com to manage your waste streams and access additional disposal documentation. * 0 Customer Service: (720)977-2102 INVOICE Customer ID: Customer Name: Service Period: Invoice Date: Invoice Number: Jul 30, 2021 If full payment of the invoiced amotilt is not received witMn your contractual terms, y u may be charged a maltNy late charge of 2.5% of the unpaid amount, with a ninimum rnontF y charge of $5, or such late charge allowed underapplicable law, regulation or contract. Page 1 of 2 1-75337-74O09 PALMETTO ENVIRONMENTAL 06/01/21-06/30/21 07/01/2021 0028612-0308-7 $50.00 If payment is received after 07/30/2021: $ 55.00 •Current Invoice Total Account Previous Balance' Payments Adjustments Charges Balance Due 1 Details for Service Location: Palmetto Environmental, 4995 York Street, Denver CO 80216-2245 Description Date Ticket Vehicle#: NONE 06/15/21 2047521 PO#:14027 PROFILE PROCESSING FEE Profile# 1331 26CO Generator WELD COUNTY GOVERNMENT(1 113 H STREET) Ticket Total Customer ID: 1.75337-74009 Quantity . Rate Measure . 1.00 ECH 50.00 Amount 0.00 0.00 50.00 0.00 0.00 50.00 Total Current Charges j, 50.00 x- --------------------------------Pleasedetachandsendthelowerportionwithpayment ---(nocashorstaples) ------------------- H , .a WASTE MANAGEMENT WASTE MANAGEMENT DISPOSAL SERVICES OF COLORADO, INC. PO 80X 43350 PHOENIX, AZ 85080 (720) 977-2102 (970) 686-2800 TICKET COPIES 030800DD3,753377400900028611200D000050000000000500u 9 003603201AB0.125 {UTQ TOO 7183B021fi-22x593-00•I•P36068-I1 1030,L0I i ll'IIIIIlIII{IIIIIIItliiilIIII11111II1Il11(11l1IIIN111l111fell I1{1111{IIIIIII{I1j1{JIllulll'i1I'll1f111111111111111111III11i1 WM CORPORATE SERVICES, INC. c" x PALMETTO ENVIRONMENTAL Remit To: AS PAYMENT AGENT C 4995 YORK STREET"{ PO BOX 7400 O DENVER CO 80216-2245 PASADENA, CA 91109-7400 C" ® THINK GREEN. Pr nMd rtn C Esther Gesick From: Chris D'Ovidio Sent: Monday, February 7, 2022 3:54 PM To: Esther Gesick Subject: FW: 1113 H St. Reimbursement Applications and Invoices Here is a little more on the process for the reimbursement process Christopher D'Ovidio Accounting Department 1150 O Street Greeley, CO 80632 tel: 970-400-4447 email: cdovidio@co.weld.co.us LRri Confidentiality Notice: This electronic transmission and any attached documents or other writings are intended only for the person or entity to which it is addressed and may contain information that is privileged, confidential or otherwise protected from disclosure. If you have received this communication in error, please immediately notify sender by return e-mail and destroy the communication. Any disclosure, copying, distribution or the taking of any action concerning the contents of this communication or any attachments by anyone other than the named recipient is strictly prohibited. From: John Drafts <JDD@palmetto-environmental.com> Sent: Monday, February 7, 2022 2:57 PM To: Chris D'Ovidio <cdovidio@weldgov.com>; David Springer <dspringer@weldgov.com> Subject: RE: 1113 H St. Reimbursement Applications and Invoices Caution: This email originated from outside of Weld County Government. Do not click links or open attachments unless you recognize the sender and know the content is safe. Chris, Thank you for facilitating the signature from the Commissioner. Now that we have that, we will submit the original application to the OPS tomorrow. It usually takes them 2-4 months to review and bring the site in front of the reimbursement fund for approval. Once we receive payment for the other invoices, we will submit those applications and ideally the OPS will approve all funds at the same time following the reimbursement hearing. Thanks, John D. Drafts, PG Palmetto Environmental Group, LLC 4995 York Street Denver, Co 80216 303-825-8117 x 107 (o) 303-356-2645 cell From: Chris D'Ovidio <cdovidio@weldgov.com> Sent: Monday, February 7, 2022 2:51 PM To: David Springer <dspringer@weldgov.com>; John Drafts <JDD@palmetto-environmental.com> Subject: FW: 1113 H St. Reimbursement Applications and Invoices Good Afternoon Please see the attached signature sheets signed by Commissioner Scott James. Can you tell me what the expected turn around is on this? Please let me know if there is anything else I can do. Thanks Christopher D'Ovidio Accounting Department 1150 O Street Greeley, CO 80632 tel: 970-400-4447 email: cdovidio@co.weld.co.us Confidentiality Notice: This electronic transmission and any attached documents or other writings are intended only for the person or entity to which it is addressed and may contain information that is privileged, confidential or otherwise protected from disclosure. If you have received this communication in error, please immediately notify sender by return e-mail and destroy the communication. Any disclosure, copying, distribution or the taking of any action concerning the contents of this communication or any attachments by anyone other than the named recipient is strictly prohibited. From: Chris D'Ovidio Sent: Friday, February 4, 2022 4:43 PM To: David Springer <dspringer@weldgov.com>; John Drafts <JDD@palmetto-environmental.com> Subject: RE: 1113 H St. Reimbursement Applications and Invoices Hi John We will have the payments for the invoice out to you on Monday the 8th. I will also have the signature sheets signed on that day as well. Just an item of note the attached request did not have a signature page, so I printed a copy from one of the others. Thanks Christopher D'Ovidio Accounting Department 1150 O Street Greeley, CO 80632 tel: 970-400-4447 email: cdovidio@co.weld.co.us . rp Confidentiality Notice: This electronic transmission and any attached documents or other writings are intended only for the person or entity to which it is addressed and may contain information that is privileged, confidential or otherwise protected from disclosure. If you have received this communication in error, please immediately notify sender by return e-mail and destroy the communication. Any disclosure, copying, distribution or the taking of any action concerning the contents of this communication or any attachments by anyone other than the named recipient is strictly prohibited. From: David Springer <dspringer@weldgov.com> Sent: Thursday, February 3, 2022 4:38 PM To: Chris D'Ovidio <cdovidio@weldgov.com> Cc: John Drafts <JDD@palmetto-environmental.com> Subject: FW: 1113 H St. Reimbursement Applications and Invoices Chris, Can you answer John's question? This is the packet of paperwork I brught up to you the first part of January. David Springer Director, Fleet Services Weld County Government 1399 N. 17th Ave. Greeley, CO 80631 970-400-3513 970-673-5007 cell Confidentiality Notice: This electronic transmission and any attached documents or other writings are intended only for the person or entity to which it is addressed and may contain information that is privileged, confidential or otherwise protected from disclosure. If you have received this communication in error, please immediately notify sender by return e-mail and destroy the communication. Any disclosure, copying, distribution or the taking of any action concerning the contents of this communication or any attachments by anyone other than the named recipient is strictly prohibited. From: John Drafts <JDD@palmetto-environmental.com> Sent: Thursday, February 3, 2022 4:31 PM To: Morgan Tice <mtice@weldgov.com> Cc: David Springer <dspringer@weldgov.com>; Katie Drafts <Katie@palmetto-environmental.com> Subject: RE: 1113 H St. Reimbursement Applications and Invoices Good afternoon, Can you please update me on where we stand with having the signature page signed as well as payment for the invoices attached to the previous email? Thanks, John D. Drafts, PG Palmetto Environmental Group, LLC 4995 York Street Denver, Co 80216 303-825-8117 x 107 (o) 303-356-2645 cell From: John Drafts Sent: Friday, January 7, 2022 9:40 AM To: mtice@weldgov.com Subject: FW: 1113 H St. Reimbursement Applications and Invoices Good Morning, David springer requested I also send you these documents related to the cleanup of the fuel release. Please let me know if you have any questions. Thanks, John D. Drafts, PG Palmetto Environmental Group, LLC 4995 York Street Denver, Co 80216 303-825-8117 x 107 (o) 303-356-2645 cell From: John Drafts Sent: Thursday, January 6, 2022 12:02 PM To: David Springer <dspringer@weldgov.com> Subject: FW: 1113 H St. Reimbursement Applications and Invoices David, It likes like Katie sent these to the admin group? The attachments with the dates are reimbursement applications that the Board Chairman will have to sign (page 4 of each application). The other two attachments labeled invoices are the outstanding invoices that need to be paid. Once we receive the checks and signed signature pages associated with the applications we will get all of this submitted to the OPS for reimbursement. Please let me know if you have any questions. Thanks, John D. Drafts, PG Palmetto Environmental Group, LLC 4995 York Street Denver, Co 80216 303-825-8117 x 107 (o) 303-356-2645 cell From: Katie Drafts <Katie@palmetto-environmental.com> Sent: Thursday, January 6, 2022 11:36 AM To: John Drafts <JDD@palmetto-environmental.com> Subject: FW: 1113 H St. Reimbursement Applications and Invoices From: Katie Drafts Sent: Tuesday, November 16, 20212:16 PM To: bconnolly@weldgov.com Subject: 1113 H St. Reimbursement Applications and Invoices Hi Barbara, I've attached several items that need to be passed through the County Board of Commissioners. Palmetto has created 3 invoices and reimbursement applications for the remediation work being performed at 1113 H St. Below is the status of each: Invoice #1— PAID (thank you!) Reimbursement Application 4/7/21— 5/6/21— Needs approval and signature on Page 4 by the Chair — Board of County Commissioners (Aff Proof of Payment has been signed by Palmetto.) Invoice #2 — Both 15040 and 15040Z need to be paid. Reimbursement Application 5/10/21— 6/28/21— Needs approval and signature on Page 4 by the Chair— Board of County Commissioners (Palmetto will sign the Aff Proof of Payment once payment is received.) Invoice #3 — Both 15076 and 15076Z need to be paid. Reimbursement Application 6/30/21— 9/27/21— Needs approval and signature on Page 4 by the Chair — Board of County Commissioners (Palmetto will sign the Aff Proof of Payment once payment is received.) Once payment is received and signature pages are signed and returned, Palmetto will submit all costs over the $10,000 deductible to the Petroleum Storage Tank Fund for reimbursement. Please let me know if you have any questions. Thanks! Katie Drafts Reimbursement Coordinator/Office Manager Palmetto Environmental Group, LLC 4995 York St. Denver, CO 80216 P: 303.825.8117 x.100 www.Palmetto-Environmental.com katie(«�oalmetto-environmental.com PALMETTO ENVIRONMENTAL CROUP LLC COLORADO PETROLEUM STORAGE TANK SUPPLEMENTAL REIMBURSEMENT APPLICATION FUND Short Form S (2017) This form should be used, and can only be used, on Supplemental Reimbursement Applications when the RAP # Applicant has already established eligibility for reimbursement of remediation costs relative to this occurrence. CBLE/OPS internal Use only The nature of this Supplemental Reimbursement Application Is: [Select all that apply] Additional costs not previously reimbursed. ► X Other (Explain): List RAP # of last application previously filed for this remediation: Applicant's Full Social Security # or Federal Legal Name, Weld County Government 84-600081.3 Tax ID # Contact Person: Barbara Connolly Phone # 970.400.4445 Fax # Mailing Address: Street: 1150 0 Street Email: bconnolly®weidgov.com City: Greeley State, CO Zip 80631 Reimbursement Remit Entity: Mailing Address (if different): Street: City: State Zip Email Applicant is (select one): , Government Site Name: Weld County Fueling Facility Site Address: Street: 1113 H Street City: Greeley State CO Zip 80632 Complete this section only if you want the representative to be the primary contact and copied on all correspondence. Applicant's Name Palmetto Environmental Group Email: mail palmetto-environmental.com Representative Address 4995 York St. (if applicable) Phone/I 303.825.8117 City Denver State CO Zip 80216 Fax/I 303.534.5049 Total from Listing of Costs, last column: $124,860.38 Less reimbursement from any other source (see #5): NET REIMBURSEMENT REQUEST: $124,860.38 Dates of work covered by this application: From: 6/30/21 To: 9/27/21 For OPS Use Only Facility ID: Type: Date Received by OPS Event ID: Technical Reviewer: Last RAP: Fund Analyst: OPS Revised From Date Revised To Date Amount After Converted Revisions REV 814117 `Prior versions of this application will not be accepted Page 1 of 4 Si natory Page Applicant: Weld County Government Legal Name of Applicant 84.6000813 Scott K. James, Chair - Board of County Commissioners Print Name a Title of Authorized Officer Complete if this is a replacement signatory page RAP# FACILITY IN/I EMAIL TO: cdte PSIS Reimbur;mentAppsCstate.co.us If you have any questions please consult the OPS website and/or contact OPS at (303) 318-8510. OPS website: ip//www.cojorado.Rov/oDs REV 814117 "Prior versions of this application will riot be accepted Page 4 of 4 'Y4 PALMETTO L N V I RONMG,NI AL GROUTLLC Affidavit: Proof of Payment (Revised 1/5/2016) This form should be used when an applicant submits an affidavit as proof of payment for costs claimed for reimbursement. This form is not required if copies of canceled checks or other bank confirmations of payment are provided. Please note the following requirements. • This form must be reproduced on the company letterhead of the payee (not the applicant's letterhead). o Affidavits that are not on the payee's letterhead will not be accepted. • This form must be signed by the payee, not the applicant. • Use a separate affidavit for each contractor. • Do not use this form if there is any affiliation or relationship between the applicant and the payee. More information is available in Section 8-2 (b) (2) of the Petroleum Storage Tank ..egul Irons. Applicant Information Applicant Name: Weld County Government Site Name: Weld County Fueling Facility Site Address: 1113 H Street City: J Greeley State: CO ZIP: 80632 Payee Information and Certification Check the following, as appropriate. Z I, being first duly sworn upon oath and being of lawful age, state that the following invoices relative to the referenced application for reimbursement from the Colorado Petroleum Storage Tank Fund have been paid in full by the applicant. 0 I, being first duly sworn upon oath and being of lawful age, state that the following invoices relative to the referenced application for reimbursement from the Colorado Petroleum Storage Tank Fund will be paid in full by the applicant upon receipt of the reimbursement in accordance with a promissory agreement. o Provide a signed and notarized copy of the agreement. Invoice # Invoice Date Amount Paid Invoice # Invoice Date Amount Paid 15076 11/10/21 $123,624.14 15076Z 11/10/21 $1,236.24 • I further state that there is no relationship or affiliation between myself and the applicant. • I hereby certify that the foregoing information is correct to the best of my knowledge, information and belief. I understand there are severe civil and/or criminal penalties for any false statement or misrepresentation of a material fact, knowing it to be false, or failing to disclose a material fact with the intent to defraud. Signature: Date: Printed Name: John D. Drafts Title: I Principal Phone #: 303.825.8117 Company (Payee) Name: Palmetto Environmental Group Company (Payee) Mailing Address: 4995 York St City: Denver State: CO ZIP: 80216 Notary Public Certification Subscribed and sworn to before me in the county of , State of this day of , Notary Public Printed Name: Signature: My Commission Expires: (303) 825-8117 - 4995 York Street El Denver, Colorado 80216 ,3 mail@palmetto-environmental.com COLORADO PETROLEUM - STORAGE TANK FUND Photocopy additional pages as necessary LISTING OF COSTS Primary Invoice #1 15076 Contractor Name Palmetto Dates of Work2 xxfxx/xx xx!x lxx Beinninq Ending 6/$0121 9/27/21 'Proof o€ Payment Invoice Amount $123,62414 Amount Submitted for Reimbut'sement5 $123,62414 Canbeled Check3 Other4 AFF Check # Check Amt 150762 Palmetto 6/30121 9/27/21 AFF $1,236 24 $ %,236 24 TOTAL SUBiuli TED FOR ReIMBURSEMENT CONSIDERATION: $124,860.38 I List 5t) PRIMARY invoicefi If invoice does not talearly identify work performed, add that information to the invoice copy submitted with the application 2 List invoices in order by the date of work peiforhied 3 If proof of payment is by canceled check, back 9f canceled check is 13lso required if the dollar amount is not encbded by the bank on the front of the check 4 If proof of payment is by payee affidavit or CPA Certification, use folltwing codes AFF = Affidavit CPA = CPA Certification of Paymdnt Use CDLE Form 5 List only ALLOWABLE costs If amount requested differs from invoice amount, identify on the invoice any cost for which reimbursement is NOT requested M Customer ID: Customer Na, n Service Period: Invoice Date: Invoice Number: Customer ID: 1-62687-24004 Details for Service Location: Palmetto Environmental, 4995 York Street, Denver CO 80216-2245 Page 3 of 3 1-62687-240O4 PALMETTO ENVIRONMENTAL 07/01/21-07/31/21 08/02/2021 0033162-1528-8 Description Date Ticket Unit of P Quantity Measure Rate Amount I Manifest#: 518729 0.00 Ticket Total I 1,542.13 Vehicles: boom 107/02/21 171921 0.00 PO#:14027 I 0.00 Cont. Soil - Petroleum 9.00 i ECH 100.00 900.00 Haz-Subst3nce Response Fee Drum 0.31 Profile # 133Q99CO I 0.00 Generator cVEC0'C0IJFITY G0VERNME`1T i I 000 Manifest#:506754 i I I 0.00 Ticket Total i 900.81 Vehicle#. boom 67/02/21 1 171922 0.00 Cont. Soil - Petroleum I 3.00 : ECH 100.00 ( 300.00 Haz-Substance Response Fee Drum 027 Profile # 127041CO ' I 0.00 Generator FARMERS MARKET CO (9491 V1 44TH AVE) • 0.00 Manifest#: 506 733 •I , 0.00 Ticket Total 300.27 V chicle 0: boom :07/02/21 171923 0.00 Cont. Soil - Petroleum 500 1 ECH 10000 500.00 Haz-Substance Response Fee Drum a45 Profile # 127033CO 0.00 Gererator SLVERTHORME SHELL (1 20 BLUE RIVER I 0-00 PK`01Y) Manife;t !. 506752 ono Ticket Total i 500.43 Vehide#: NONE 07/23/2! 172073I 0.00 Recertification Fee 1.Z'0 ECH 35.00 35.00 Profile # 130409C0 0.00 Generator MAGIC RABBIT (bo51 COUNTY LIME RD) ; 0.00 Ticket Total 35.00 Vehide#: lift gat.07/2-3/21 172 I J0 .00 Cont. Sod - Petroleum 3.00 ECH 100.•70 300.00 Ha: -Substance Re;pon;e Fee Drum I 0.72 Profile N 13040900 Q 00 Generator MAGIC RABBIT f 5651 COUNTY LINE RD! D Do Manife;tt: 1010:3501 0.00 Ticket Total 800.7272 Total Current Charges 4,880.10 THINK GREEN. YY l WASTE MANAGEMENT Visitwm•com To setup ycur crlire profile, sign. up fcr paperless stay -mends, ma -!age your account. view hdiday schedules, pay your it cice er xhedde a pickup INVOICE Customer ID: Customer Name: Service Period: Invoice Date: Invoice Number: Aug 31, 2021 If U payment of the incited ar:cunt is rot recei.ed Md- n ycur contra" terms, ycu may be 9ed a ye dirge of 2.5% of unpaid arrow h 3 nirirnum n-crtHy dty'e of $5, or such late d'age Customer Service: I Mowed xder apFlic a law, reguIatkn cr catfl (720) 977-2102 301.26 0.00 r • ..��4aYf.•-. wY -Jiy• Details for Service Location: Palmetto Enviro 4995 York St, 4995 York St, Denver CO 80216-2245 Description V?hide*: 414213 — hULK RUN DRUMS MAX;'.1 ;,t - P 2 Fuel charge ES Manifest*: 519723. 50675-4. 506753 Box *: 2 5 Drums rn RIG#: HR • Ticket Total Total Current Charges x Date w Ticket 156662 Page 1 of 2 16-81940-83002 PALMETTO ENVIROMENTAL 07/01/21-07/31/21 08/02/2021 0814538-2803-0 $302.17 If payment is received after 08/31/2021: $ 307.17 Total Account Balance Due r , Customer ID: 16-81940-83002 Unit of — — Quantity f Rata I Amount Measure 1.0000 DM . 2000000` 260.00 1.0000 Fat 42.1730 42.17 0.00 0.00 302.17 302.17 �+---------------------------------Pleasedetachand3endthelowerportionwithpayment---(nocashorstaples)----------------_ • wwa7E MapaawMwNr Nd3T_ Y1APNA3ENIEP4T OF GjLJP.30}) iPiC_ I i35 WELD coupire PD 5i C `IE33UPG _J 't)8 -i3 --v- 16-81940-83002 Payment Terms Tot 31 Due by �`31r20'I If Rece!,ed art?r JZ!3I; 2:0; Total Due 53-"i' Amount 28030001681940830020081453800000030217000000302L7 5 I; ... . , ., Ilillirrr}Irli}rr.I..Irrr}rllnl}}66611}Illili}Ilil}}}rlrllrll/ri I}VIII}ilr}llllrllrilrulilir}Iliillllll!nl!illllll!lilllllllli WM CORPORATE SERVICES, INC. PALMETTO ENVIROMENTAL "T' AS PAYMENT AGENT 4995 YORK ST AS *jY PO BOX 7400 DENVER CO 80218-2215 PASADENA, CA 91109-7400 THINK GREEN. NON -HAZARDOUS 1. Generator ID Number 2. Page 1 of 3. Emergency Response Phone 4. Waste Tracking Number WASTE MANIFEST 800-424-9300 5. (j ner@tor's Name and Mailing Address Generator's Project Address (if different than mailing address) 13 T 1L�4— 5 Generator's Phone: 6. Transporter 1: Complete Company Name and Address Transporter Phone 7. Transporter 2: Complete Company Name and Address Transporter Phone 8. Designated Disposal Facility Name and Site Address Facility's Phone: 9. Waste Shipping Name, Description, & Profile Number 10. Containers 11. Total Quantity 12. Unit WWoI. No. Type 1. O 04C © (J I W 2. 13. Regulatory Agency: Colorado Department of Public Health and Environment Emergency Notification: 4300 Cherry Creek Drive South CHEMTREC (800) 424-9300 Denver, Co 80222-1530 24 -hour Toll Free Number 14. Bill to & Account Number 15. Contractor/Generator Certification: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name, and are classified, packaged, marked and labeled/ placarded, and are in all respects in proper condition for transportation according to applicable national and state governmental regulations. I hereby certify that the above described waste is not a hazardous waste defined by federal, state or local regulations and does not contain regulated quantities of PCB's or radioactive materials. Generator's/Otferor's Printed/Typed Name Signature Month Day Year a 16. Transporter Acknowledgement of Receipt of Materials Transporter 1 Printed/Typed Name Signature Month Day Year 0 a N a Transporter 2 Printedfryped Name Signature Month Day Year It H 17. Special Handling Instructions 18. Discrepancy Indication Space: 19. Ticket # LL W Z Initials of Person noting discrepancy Signature Date 20. Management Method/Location to W G Landfill Monofill Location: 21. Designated Facility Owner or Operator: Certification of receipt of materials covered by the manifest except as noted in Item 18 Printed/Typed Name Signature Month Day Year 169-BLC-O 6 10498 (Rev. 9/14) 1 �PaceAnalytical www pacelabs com Sold To John Drafts Palmetto Environmental 4995 York Street Denver, CO 80216 303-825-8117 x107 II e®� ra Pace Analytical Services, LLC �0 '9ii, 9608 Loiret Blvd Pace Analytical Services LLC 41-1821617 Lenexa, KS 66219 Pace Analytical National 62 0814289 Phone (913)599-5665 Pace Analytical Gulf Coast 45 4027089 Invoice Number 2160137818 Date 07/29/2021 Total Amount Due $260 00 Please Remit To Pace Analytical Services, LLC PD Box 684056 Chicago, IL 60695-4056 Client Number/Ghent ID Purchase Order No Pace Project Mgr _ Terms* Page 60-506268 / Palmetto Heather Wilson Net 30 Days 1 LL Client Project 1113 H Street Client Name Palmetto Pace Project No 60375807 Sample Received 7/24/2021 Report Sent To John Drafts, Palmetto Environmental Comments ANALYTICAL CHARGES Quantity Unit Description Method Matrix Price Total 4 Ea 8260 MSV GRO, BTEX, & MTBE EPA 8260 Water $65 00 $260 00 Samples Received for analysis Lab ID Client Sample ID 60375807001 MW -01 60375807002 MW -02 60375807003 MW -03 60375807004 MW -04 Total Number of Charges 4 Received 7/24/2021 8 40 00 7/24/2021 8 40 00 7/24/2021 840 00 7/24/2021 8 40 00 If you have any questions, please contact Heather Wilson at Pace Phone 1(913)563-1407 Email heather wson@pacelabs com Analytical Subtotal $260 00 Total Invoice Amount $260 00 Page 1f1 1 1 5% MONTHLY FINANCE CHARGE ASSESSED AFTER 30 DAYS OR TERMS OF CONTRACT PACE RESERVES THE RIGHT TO SURCHARGE ON CREDIT CARD PAYMENTS BASED ON CARD TYPE AND ZIP CODE PLEASE REFERENCE THE INVOICE NUMBER ON ALL REMITTANCE ADVICE AN EQUAL OPPORTUNITY EMPLOYER Please complete and return copy of invoice with your payment INVOICE TOTAL $260.00 Amount Paid $ Check No Customer No 60-506268 Invoice No 2160137818 Petro Waste Sokifions LLC 4995 York Street, Unit B Denver, CO 80216-2245 USA Voice 303-825-8117 Fax 303-534-5049 Palmetto Environmental Group LLC 4995 York Street Denver, CO 80216 Weld County Government 1113 H Street Greeley, CO 80631 Palmetto Waste Manifest #1751 1 Net 30 Days Hand Deliver 7122/21 9/17/21 1 00 VT 70 81 Vac Truck/Purge Water Removal Event ID 14027 70 81 Check/Credit Memo No Subtotal 70 81 Sales Tax Total Invoice Amount 70 81 Payment/Credit Applied PETRO WASTE SOLUTIONS Time And Materials Sheet Weld County Government Job Name: 1113 H Street Greeley, CO 80631 Description of Work: Purge Water Removal Date: 7/22/21 Item Rate Unit Amount Ibeimbursment Codes Total Mileage 0.575 Miles 117.4 9.4 $67.51 Travel Time 75 Hours 5.5 $0.00 On -Site Time 75 Hours 5.5 $0.00 Misc. Field Supplies 25 Day 12.1 $0.00 Mileage DOT Truck 2.75 Miles 9.4 $0.00 Travel Time 80 Hours 13.99 $0.00 On -Site Time 80 Hours 13.99 $0.00 Vacuum Trailer 110 Hours 13.99 $0.00 Water Disposal 0.6 Gallons 5.5 14.3 $3.30 AS/SVE Pilot Test Skid 1,300.00 Day 14.2 $0.00 55 Gallon Waste Oil Drum 55 Drum 14.2 $0.00 Part 14.2 $0.00 Part 14.2 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Total $70.81 Waste Manifest #1751 Purge Water: 5.5 Event ID: 14027 6 PETROWASTE SOLUTIONS - NON -HAZARDOUS WASTE MANIFEST 1751 1. Generator's US EPA ID Number Manifest Document Number 2. Page 1 of 3. Generator's Name and Mailing Address ic Ol n / 5. Generating Location (if different) / �t/vnYhBn 1)13 44 SVee.4 4. Phone ( ) (7cet1 e- to f pIo3I 6. Phone ( ) 7. Transporter #1 Company Name 8. US EPA ID Number 9. Transporter #1's Phone 10. Transporter #2 Company Name 11. US EPA ID Number 12. Transporter #2's Phone 13. Designated T/S/D Facility Name and Site Address 14. US EPA ID Number 15. Facility's Phone Petro Waste Solutions CO52329-10798 (303) 356-2645 4995 York Street, Suite B Denver, CO 80216 16. Waste Shipping Name and Description 17. 18. Containers 19. Total 20. Unit Quantity WtA/oI No. Type a. Unleaded Gasoline Contaminated Water Gallons tx O t-- b. < Diesel Contaminated Water Gallons w z .t H. tir d. 21. Additional Descriptions for Materials Listed Above 22. Special Handling Instructions and Additional Information 23. GENERATOR'S CERTIFICATION: I certify the materials described on this manifest are not subject to federal regulations for reporting proper disposal of Hazardous Waste. 1 ! / Signature Month Day Name r 9 / Year tY 24. Transporter #1: Acknowledgement of Receipt of Materials W Printed/Typed Name Signature Month Day Year M 25. Transporter #2: Acknowledgement of Receipt of Materials Z 4 Printed/Typed Name Signature Month Day Year tY I- 26, Discrepancy Indication Space >. J Q 27. Facility Owner or Operator: Certification of receipt of waste materials covered by this manifest (except as noted in Item 19) 4 LL NHWM 06/0 Printed/Typed Name Signature Month Day Year To order more forms call: 480-8047328 TRANSPORTER invoice V�elpine REMEDIATION Due: Nei 30 Chris Bird Fed ID- 26-4356753 Palmetto Environmental Group Invoice No. AR12535 4995 York St Date' 3 -Sep -21 Denver, Colorado 80216 Project No ARP1923 Location- 1113 H Street Description: BOS-200® for Excavation Date(s): August 13, 2021 P O, Number: 14027 BOS-200®, Product Only 2,000 pounds x $6/pound $ 12,000 00 Trap and Treat® Bacteria 5 gallons x $100/gallon $ 500.00 Freight Lump Sum $ 1,000.00 Total Fee: $ 13,500000 REMIT PAYMENT TO AL PINE REMEDIATION, INC , 14252W 44th Aye, Unit G, Golden, Colorado 80403 For Questions or Concerns, contact Theresa Sorrells, ALPINE REMEDIATION, INC - (303) 868-7736 My Electrician Ltd. 395 S. Quail st Lakewood, Co 80226 720-260-9995 Jerem yWillFixYou@Gmail.com Bill To: Tyler Kalous Palmetto Environmental Group LLC 4995 York St Denver, Co 80216 Work Location: 1113 H St Greeley, Co 80631 INVOICE DATE: August 20, 2021 INVOICE # 1740 Project PWR Disconnect Please make payments to address above within 30 days. THANK YOU FOR YOUR BUSINESS! Blood Hound, LLC P.O. Box 715409 Cincinnati, OH 45271-5409 1-888-858-9830 - Office AR@bhug.com - Email Palmetto Environmental 4995 York Street Denver, CO 80219 Attn: Tyler Kalous Item Advantage Locate (hourly rate) Invoice No: 457789 Work Order Number: WO -00178634 Project Location: 1113 H St., Greeley, CO 1113 H St. Greeley, CO 80631 Date of Invoice: Due Date: Period: Payment Terms: Quantity Rate 2 $165.00 Balance Due 5% monthly service charqe after 30 days a__ cot HOUND flu • U Y1tl11Y 1.[u1WY li HljJ•: •• L•112. dA p 8/17/21 9/16/21 8/17/21 - 8/17/21 Net 30 Total $ 330.00 $ 330.00 REMITTANCE UPDATE NEEDED: Please refer to final page of this invoice for further information. I of 2 Date Pnnted: 3. 19;21 INVOICE Custom Fence 3031 Highway 119 Longmont, Colorado 80504 Phone: 303-651-5719 Fax: 303-651-5745 2021 SUBDIVISION JOB ADDRESS PO NUMBER CLIENT JOB # SECTOR 303-651-5700 SINCF 19811 BILL TO PALMETTO ENVIRONMENTAL GROUP LLC ( 4995 YORK STREET 12189181 DENVER GREELEY 1113 H STREET Phase:3.75 Qnty Description CO 80216 INVOICE DATE 8/17/2021 NET 15 DAYS JOB NUMBER 1421 Install On PER AMOUNT 264 Install Temp Fence AUGUST 2021 $3.75 $990.00 SUB TOTAL $990.00 WRAP $0.00 INVOICE / CC EMAIL NET AMOUNT $990.00 Work Completed Approved By Date Requested By TYLER KALOUS - (970) 301-0607 Invoiced - PO Missing Office Phone (970) 301-0607 Fax When you provide a check as payment, you authorize us either to use information from your check to make a one-time electronic fund transfer from your account or to process the payment as a check transaction. When we use information from your check to make an electronic fund transfer, funds may be withdrawn from your account as soon as the same day you make your payment, and you will not receive your check back from your financial institution. If you have any questions regarding your billing Please contact Amy Smith @ 303-651-5719 or email amy.smith@cofence.com Primed: Tuesdn•..4uqust 1'. '0 1 /19:28 am r✓c — I4t JCl Ydd.C L4.447t1V11e iU GVtCsd tM1f. t —.r ✓.,—, —svv,W Palmetto Envi€ronmental, 4995 York Street, Denver CO 60296-2245 Description Vic•' 5...: - Fe ro,etn-; ra Sdbs.ance Response Fee Yard' . , " ;r.:e 9 1331 26600 F•" _ G . ' b':rELDCCUF1TYG0'YERNM.ctd (1113H "01615514 Ticket Total f Q�' Automatic Payment .r<.:, Pay Through Your flnahcia! Institution one -Time Payment Pay by Phone � x lF' -: r''t`MriV+k'vl. r ' Unit of Date Ticket Measure 12.00 YDS 20.001 240.00 4.20 0.001 E i 0.001 0.00 ..--- �. _ _ _ �t4 .-1_ . ... 244.20 . Saves:'leda'e^a} 7 dretaWaMe 'Vi e —e-` My?tg o d r a date -ay pit wm.com -it., add: cna c^da•ges Ymr Total Due s vw August 19. 2017 $124.73 :maa°^o.ax-nle.a '7:c a•eda�°j etos.Bland`8aa .es co-- ,ed Apr e ! Pe -c-. cos:° :v°adfn--our axu i. x c'euas >ace We x- .° a- rPayments ;f, • • - Received/Adjdutmeuts axi adsl yn-r . _ i Current Charges Fds c*as t<' •dg cgc v !,, .. . 7]A 73 W a Total Due d$`d r s '7kuce H ge. y'a1':a - u uada o a '-viofyQ. ,a%L' ;.r r..e.: x.:w r.c= s•..rer. an. -cueeay t-oee Total Due '. 'CxwxsT... .. ... __ .... _. . ..,^ _.. v. avoda we c-%& ge o, wa.:a 2:c' a v*r , r :a �.aeaaer, rase. _ WAT' - Ctv-10ii3t`iNitin(, 1' At Mt I10INVII,'UNh11.NIAt S�rvit.t, f#'tIIxI (1(r /t> 1/)1 i)il/ t l /21 111Y ?ICU I t !lt'' C 9(01//I1'/ 1 InvNtinhel: (1OM81P, 1) 300 0 I C w Detnll$ for $cat vice i ovation. Pal motto Env rilnm00tal, 409:3.York Street, DenVor CO GtlsCotrltI1 IDt 002140 1 714000 I�gssrlEatton 8nt Tlekat qunrattry tlUlk of Rc+tu �tntiauet ! rofiie 3 S_.. Maesurq _ .. i n c?i1 GonsrottarW;-t,UCOUN]YO(1VI:NNMMCNT(111311 (1(x) STRi31iT) hlarilfesta: 10G 1 *,550 1) 00 Ticket Total Vehlclelt47 VO4 013/111121 /0113.7- 14027 O.pO S Cont Soil Pt oNum tlaz Substatse4 Rasponn.o Foc Yards 1, .00 YE>5 X0.00 740.00 Proflor 133_''26CU 000 GeneratVi- WCt;p COUN ['Y G9V1'.RNM1IINT(1113 II 0220 ST{it CT} lviahtPcst3E 1Q61SSS8 0200 Ticket Totnt 244.20 Wk.laa OQ7 AO 14027 08119/21 20136 304 (100 Cont Soil patrolevm HazSubstenc� Responsefee (aids 11.00 YI'S - 20,01 0110 - 24000 - prole a 1331;2sc0 11Q eiacretor Wt7 O COt1NT1;GOVCRNM1 NT(1113 U. 000 r . sTR1et') 000 rylRt to 1O -1552S Tl4lce}Total .; 000 44.0 .. Vehie 129 •013/10/21 20136401 000. 0#.14027 S0.01) Cofl1 Soil Aetro)eum Nab Set a5taanta Reap p tse Asti Yards 1800 YDS 2000 36000 Prolta r 133121300• GeneratVr WCID COUNTY 10 0.1)0 OOVERtdh1ENT(1113 It. $TRC(T)• 000 Manifests 1061&526 S 000 Ticket Total ' V •36 .30 . Vehicles 002 0$/18/21 2066406 0•00 P '14027 000 Go11t. Sal Retrleu(n F 12.00 '(08 20 0Q 61 O Cr N axSUbsYance R@sponse Re Yards PrafilE 13312 00 0 0 Generator WlLA; 0UN'1Y G(?VCRNMENr(111$ li 00 $1 RFRF) 000 kit lfest1I 10615527 • Ticket Total oq 20 Vah't]e✓F 17 08/18/21 2i]G6A15 0`0 R 1 RV414027 - ,0 Cant.Soil AetroleUna .... • • X1200 Y4. .`. 2000 240Of1,± ,. yt i 1). .aa L 3 lVI 1: '7 {j iiQ.St7t.3°a;4 _ _ __- ___ _ _ _-_ _ - - -.....bA.:r.ss,&.:F:g5.e'C�ySK'.+.:-.'n3'i.ice-•t-wrifia•i3:".�i�F.ti£�"v. ¢_�3+�.:i�oS'�"Y"�,'`e`-' ti -r •� � k r`=�in�r• a .y.k-. ti .a .f tq,+ .I aY;o.T °t` a � r 3)t wnsern nnn,unnr.Kwe`xes+ NON -HAZARDOUS M A N i F E T NON -HAZARDOUS MANIFEST 2. Generator's US EPA ID No, Manifest Doc No, 2, Page 1 of 3. Generator's Mai)ng Address: q � f-1Yh.'4' I Generator's Site Address (n diferentthan meningl, WELD A. Manifest Number w �i l nr1 COUNTY GOVERNMENT WMNq 10615518 j 1113 I -1 STREET B. State Generator's ID .4Q(?1-� GREELEY, CO 80631 4. Generator's Phone 303-825-8117 S. Tian patter I Company Name h Itj �G 6. US EPA ID Number C. State Trans orter's ID •:!':�, - .,r r' _• 1 6-C, r �i $� rGt r� G�) 7. Transporter 2 Company Name B. US EPA ID Number D. Transporter's Phone } • E. State Transporter's ID :.I „_ r! . ,• I ifl. US EPA ID Number R Transporter's Phone..'P- i,, :a ;;'!. ` 9. Designated Facility Name and Site Address NORTH WELD LANDFILL G. State Facility ID ':*...: •. I":::' 40000 WELD COUNTY RD 25 H. State Fadilty Phone 970-545-5015 AULT CO 80610 f.. 11. Description of Waste Materials 18, Contelners is. Total 14, unit nl. No. NPo (�' quantlty Wt./ I, Mlsc, Comments E a. NON REGULATED SOLID —EXCLUDED LIST CONTAMINATED N SOIL ;,1: 'o� E A WM Profile # 133126CO ' ! r .rti! 11' rilii;!`:�!: ii ;.':f,:!: tai? '•.. li. "R', R WM Profile # , i:I t : i' i,'. r, r:,: ;�.L.. :.i ;.- Gil' { ii' 6�; ''r�'. ,4;,;:: C. r Ir," WM Profile # i J; ry :r•'. ! LI v d, WM Profile # ir' ;'; r.l.! ;,., lil . �� a ' "^ "' ::, : f}, • r' ii: �.,,.. J. Additional Descriptions for Materials Listed Above K. Disposal Location y ACCT'#: N 10039 CUST NAME: PALMETTO ENVIRONMENTAL Cell Level Grid w: vsv.,v. „, „u nv,y,:.,v,111w1, IQ 47 I Purchase Order It 14027 EMERGENCY CONTACT/ PHONE NO.: 1-800-424-9300 24HR TOLL FREE 16, GENERATOR'S CERTIFICATE: I hereby certify that the above -described materials are not hazardous wastes as defined by CFR Part 261 or any applicable state law, have been Fully and accurately described, classified andpackaged and are in proper condition for transportation a rding to applicable regulations. Printed Name fj Signature "Oh behalf of Month Dan Yaar T 17. Transporter 1 Acknowledgement a Receipt of Materials O e A Printed N e Signature 0 18. Transpo ar 2 Acknowledgement of Receipt of Materials T Printed Name Signature Month oay Year 19. Certificate of Final Treatment/Disposal n I certify, on behalf of the above listed treatment facility, that to the best of my knowledge, the above -described waste was managed in compliance with all c applicable laws, regulations, permits and licenses on the dates listed above, 20. Facility Owner or Operator: Certification of receipt of non -hazardous mat rlels co v this1• manifest, r tit_ e �ry� y f ��C J R- Signal irb oay White- TREATMENT, STORAGE, DISPOSAL FACILITY COPY Blue- GENERATOR #2 COPY Yellow- GENf BATOR #1 COPY Pink- FACILITY USE ONLY Gold- TRANSPORTER H1 COPY b • N NON -HAZARD WASTe ous MANIFEST ;NO,.N-,HtA:ZA=RDOUSAT 1, Generator's US EPA JO No. Manifest Doc No. ge 1 of A.anifestNumber FA. 3. ror's Muddling AddressGenerator's Site Address (Irdlfferentthanmrdihtill WELD COUNTY GOVERNMENT 10615514 1113 H STREET WMNA B, State Generator's ID GREELEY, CO 80631 4. Generator's Phone 303-825-8117 S Transporter i Company Name 6. US EPA I Number �;; t ,,. ate•' � I. t_. rL �, d ' r�r' t C. State Trani orter's lie '1\ 7.1 nsporter 2 Company Name 8. US EPA 10 Number D,Transporter'sPhone • -. I P : a E, State Transporter's to I r signated Facility Name and Site Address 10. US EPA ID Number F. Transporter's Phone I'I , :. I' .:: TH WELD LANDFILL r40000WELD COUNTY RD 25 t: i G. State Facility ID t, • .:., T CO 80610 H. State Facility Phone 970-545-5015 -• 11. Description of Waste Xateriats 1z.Couwlnen ia Total to unit E ><wo a. NON REGULATED SOLID— EXCLUDED UST CONTAMINATED Quantity wL/yel. L Mine. (;ornmenes N SOIL. -- R A WM Profile R 133126CO (. 4'; a ::r:." ;�: r:• . vr. b. is _ T ffi. '.iL i a" h` F',(. .r;U. . WM Profile# it' , iii, �•. .,I, n. r :.• W M Profile # 't; . •; • I ` .,:It J ' ,''.Pl 1. Additional Descriptions for M to DescMaterials rip a rlals Listed Above t, 1. l !':'t lj : ' F : ' • K. Disposal Location ACCT # : N 10039 CUST NAME:,PALMETTO ENVIRONMENTAL Level Grid 15. Special Handling Instructions and Additional Information Purchase Order# 14027 EMERGENCY CONTACT / PHONE NO.; 1-800-424-9300 24H R TOLL FREE 16. GENERATOR'S CERTIFICATE; I hereby certify that the abwe-described materials are not hazardous wastes as defined by CFR Part 261 or any applicable state law, have been fully and accurately described, classified and a ed and are in pro er condition for Iran ortation accordin to a placable re ulations, Printed Na`; Signature "On beha Month pay /vCE 6 c. it 7 r 17. ansporter 1 Acknowledgement of Receipt of Materials R - PrI Name „---`f� 5ignatu Moth oar a 18. Transporter 2 Acknowledgement of Receipt of Materials - r ItIIJI1 S nature It � Mantlt pay R , 19. Certificate of Final Treatment/Disposal I certify, on behalf of the above listed treatment facility, that to the best of my knowledge, the above -described waste was managed Ill compliance with all applicable laws, regulaUuns permits and licenses on the dates listed above. 20. F duty Owner or Operator: Certification of receipt of non -hazardous materials covere tills manifest, r P tad Na + Signature /in. Mo bay White- TREATMENT, STORAc , DJSP FACILITY COPY Blue- ERATOR #2 COPY Yellow- GENERATOR #'1 COPY Pink- FACR.ITY USE ONLY Gold- TRANSPORTER #1 COPY NONHAZARDOUS MANIFEST 1. Generator's US EPA ID No. Manifest Doc No. 3. Generator's Mailing Address: Generator's Site Address (Ifd5faeatthan tn-Illnpk WELD COUNTY GOVERNMENT 1113 H STREET r' GREELEY, CO 80631 4. Generator's Phone 303-825-8117 5. Transporter L Company Name 6. US EPA ID Number 7. Transporter 2 Company Name B. US EPA ID Number r. .iI' lgnated Facility Name and Site Address 10. US;EPA ID Number TH WELD LANDFILL. 0 WELD COUNTY RD 25 F CO 80610 ,. :• .•, ' ';yl!� .•Air'` .';'I. iiN:: • 1L Description of Waste Materials 17 CorttalnersA`L G No.Te E a, NON REGULATED SOLID — EXCLUDED UST CONTAMINATED N SOIL + I'G--- E R A W M Profile # 133126CO b. '.; 1N ,sueste m %M00enatnlrr NON -HAZARDOUS MANIFEST 2.Pagetof A. Manifest Number WMNA 10615515 B. State Generator's ID !State Transporter's ID ,..} I).TraruportiPhone I. r :,•; E. State Transporter's ID ; ;; r,• , F. Transporter's Phone t :.i • , G, State Facility ID I.JI H. State Facility Phone, 970-545-5015 .4 13. Total 14. UMt Quemoy wL/vol. I. Mlsc. Comments 0 WM Profile# :! . �^ C. 5 ..,. .- . ..__&., .---- ''. R;•pr :.u• i. WM Profile It t•1 , d. W •WM Profile # '.'; R.................... i,l .. :... .,. . J. Additional Deser►pttons for Materials Listed Above K. Disposal Location ' ACCT if: N 10039 COST NAME: PALMETTO ENVIRONMENTAL a.cn LoveI Grid 15. Special Handling Instructions and Additional Information uI.:1..i.'.. •�,�r Purchase Order# 14027 EMERGENCY CONTACT/PHONE Ni 1-800424-9300 24HR TOLL FREE 16. GENERATOR'S CERTIFICATE: I hereby certify that the above -described materials are not hazardous wastes as defined by CFR Part 261 or any applicable state law, have been fully and accurately described, classified and packa ed and are In roper condition for transportation according to a Liable regulations. Print e 5 9lgnature -On behalf a Month Day Year T 17. Transporter 1 Acknowledgement of Receipt of Materials a Printed Name Sf s u 18- Transporter 2 Ac owled meat of Receipt o Materials T Printed Name Signature E Month Day Yaer 19. Certificate of Final Treatment/Disposal n I certify, on behalf of the above listed treatment facility, that to the best of my knowledge, the above -described waste was managed in compliance with all applicable laws, regulations, pennits and licenses on the dates Ili above. 20. Facility Owner or Operator: Certification of receipt of non -hazardous erial vered by this manifest. r r e Cn L Sighatu F C h Day Year White- TREATMENT, STORAGE, DISPOSAL FACILITY CORY B = GENERATOR #2 COPY Yellow- GENERATOR Ill COPY Pink- FACILITY USE ONLY Gold- TRANSPORTER #1 COPY �r• NON -HAZARDOUS was're mnlraauragglar MANIFEST NON -HAZARDOUS MANIFEST 1. Generators US EPA ID No. Manifest Doc No, 2, Page i of 3. Generator's Mailing Address: Generator's Site Address (e d!Herent than melling) A. Manifest Number WELD COUNTY GOVERNMENT 10615562 1113 H STREET WMNA B. State Generator's ID GREELEY, CO 80631 4. Generator's Phone 303-825-8117 5. Tranorteompa` spr 1 Cn Name 6. US EPA ID Number Coo v v7 1„(n p.: C. State Transporter'sID . , 1 r. 1. b''6 t� 7. Transporter 2 Company Nan $. US EPA ID Number D.Trans rter'sPhone i rr'. r' t.. • ;: I' I., . ,, I; ;� E. StateTransporter'sID (, F. Transporter's Phone 9. Designated Facility Name and Site Address 10. US EPA ID Number NORTH WELD LANDFILL. G. StateFacilltylb ;, 40000 WELD COUNTY RD 25 '• I: i!' • n! . K State Facility Phone 970-545-5015 AULT CO 80610 I �p`;��" .f1 f:' :.. .., . .1 .. :I: =,: • ,� . :fir' .,': . '., ,... ,,•, ' �.i� : ; Lis U. Description or W to M (als as eter 12, Contal}ers Told , O t4 E a. NON REGULATED SOLID —EXCLUDED UST CONTAMINATED No. Ty QvaniNy wtjyol. trop. 1. MIac.Cw 11ts SOIL h WMProfile# 133126CO a', WM Profile p ; !+. c; 1NM Profile It I:.I: It;;: A• • :a,:: " �• S}�.!.. d.cs i::. `. u. ; ,:: .__... J. Additional Descriptions for Materials Listed Above ACCT #: : N 10039 CUST NAME: PALMETTO ENVIRONMENTAL Cell Level _ srid ,3, apeuei nanoung Instructions and Additional Information T rt A N I. I. a R T Purchase Order If 14027 EMERGENCY CONTACT/ PHONE NO.: 1-800.424-9300 24HR TOLL FREE 16, GENERATOR'S CERTIFICATE; I hereby certify that the above -described materials are not hazardous wastes as defined by CFR Part 261 or any applicable state law, have been fully and accurately described, classified and packs ed and are in o er condition for transportation according to applicable regulations. Printed Nemt+' i r / y� Signatur "On behalf of" Will Day 17. Transporter 1AcknowledgementoffReceipt offMaterials 18. Transporter 2 Acknowledgement of Receipt of Materials Printed Name 19, Certificate of Final Treatment/Disposal — a I certify, on behalf of the above listed treatment facility, that to the best of my knowledge, the above -described i applicable laws, regulations, permits and licenses on the dates listed above. 20. Facility Owner or Operator: Certification of receipt of non -hazardous naterials covered by this manifest. CL, ` Slgna White- I R ATMENT, STORAGE, PIS OSAL FACILITY COPY $(u TOR #2 COPY Pink- FACILITY USE ONLY Gold- TRANSPORTER 41 COPY Month was managed in compliance with all 1�1[ ,1 ,.«e�R NON -HAZARDOUS MANIFEST 1, Generator's US EPA ID No, Manifest Doc No. NON -HAZARDOUS MANIFEST 3. Generator's Malang Address: Generator's Site Address (Ildnermt can nnatne)t WELD COUNTY GOVERNMENT 1113 H STREET GREELEY, CO 80631 4, Generator's Phone 303-825-8117 S. Transporter 1Ccnpny Name TI't C,Jyff 6. US EPA ID Number 7. Transporter 2 Company Na 8, US EPA ID Number 9. Designated Facility Name and Site Address 10. US EPA ID Number NORTH WELD LANDFILL 40000 WELD COUNTY RD 25 1 ' '- • ' • , AULT CO 80610 :I •: 1L Description of Waste Materials a, NON REGULATED SOLID— EXCLUDED UST CONTAMINATED N SOIL E R WM Profile # 133126CO O R WM Proffle# i:• C. WM ProfYe # •I:: d, 2. Page 1 of 1'. =MShINfelstumberA 10615563 B. State Generator's ID C.StateTrans orter'sID :.,. :; D, Transporter's Phone 'v' E. State Transporter's ID : ,•, F. Transporter's Phone 1 G. State Faculty ID r.:; " :hl; H. State Facility Phone 970-545-5015 u. contatrwrs 13, Total 14. Unit Na. lype lyueRtitr Wt.Nol, 1. Mt c, comments WM Profile It ::; :.: ,i ;. ..t a ; i `.^. :g i' ar :' • n:., _e.. ;w . :.r`•'' .:y;; ., ;i;: J, Ad4tionalDescriptionsforMaterialsListedAbove K. Disposal Location ACCT# : N 10039 CUST NAME: PALMETTO ENVIRONMENTAL Cell +eve! Grid 15. $pedal Handling Instructions and Additional Information Purchase Order# 14027 EMERGENCY CONTACT/PHONE NO.: 1-800-424-9300 241 -HR TOLL FREE 16, GENERATOR'S CERTIFICATE. I hereby certify that the above -described materials are not hazardous wastes as defined by CFR Part 261 or any applicable state low, have been fully and accurately described, classified and packaged and are In condition for transportation accordin to applicable regulations, PrI tedNarn Signa half Month T 17. Transporter 1 Acknowledgement of Receipt of Materials wP ted N e Signa S 18. Transporter 2 Acknowledgement of Receipt of Materials T Printed Name - Signature MoIlsh_JiiaY R 19. Certificate of Final Treatment/Dfsposal A I certify, on behalf of the above listed treatment facility, that to the best of my knowledge, the above -described waste was managed In compliance with all a Arable laws, regulations, permits and licenses on the dates listed above. i 20. Facility Owner or Operator: Certlflcatlon of receipt of non -hazardous materia overed by this manifest. TTInt me ' Signa M h oer White -TREATMENT, STORAGE, DISPOSAL FACiL1TYCOPY Blu NERATOR #2 COPY Yellow- GENERATOR OPY Pink- FACILITY USE ONLY Gold- TRANSPORTER #1 COPY /l ' trot! -1 NON -HAZARDOUS MANIFEST 1, Generator's US EPA ID No. Manifest Doc No. NON -HAZARDOUS MANIFEST 2, Page 1 of 3 generator's Mailing Address: V t Generator's Site Address pfdrfarootdtanmalllns)1 WELD COUNTY GOVERNMENT A. Manifest Number 10615516 trot (, $ '' ' ' 1113 H STREET WMNA & State Generator's ID �YYV,./'ti •� �O,L.I& GREELEY, GO 80631 4. Generator's Phone 303-825-8117 S Transporter 1 Company Name Iry 6. US EPA 1D Numbera' C. StateTransporter's IU , .; -.: q'T� 1r , D.Transporter's Phone +. : i , i:.r, 7. Transporter z Company Name 8. US EPA ID Number I .I. . . r ' i; + , , . ['I . i u i 1'' E. State Trans orter's 10 I'r Po +r; P. Transporter's Phone ;i ; : , " ::::.;•.. 9. Designated Facility Name and Site Address 1 o, US EPA ID Numbe NORTH WELD LANDFILL a N FILL G. State Facility ID 40000 WELD COUNTY RD 25 H. State Facility Phone 970-545-5015 AULT CO 80610 '}: . �tiP -ii•:: ..: u V✓. a' .:..S. .ai ..:: _ I,i:.'. :f' •. .. 5{Ci 1 S 11. Description of Wastematerlais 1z, Cc tamers* 33,Total 14."Unit No. 'type E a. NON REGULATED SOLID —EXCLUDED USTC0NTAMINATED Quantay Wt./VoL I. Mlle. t:ommenh N SOIL i 1 (::It'+' II WMProfUeif 133126CO :I * { T 0 ;.. 1 •..,.., R WM Profile # WM Profile 0 ,,f •€ i :.a:l,: ::: .+ . �,rl rs;"' a. , .. lli WM Profile It +.:.i t . i'? 1:1i :I, l ':: a :i:. J. Additional Descriptions for Materials Listed Above K, Disposal Location ACCT# : N 10039 CUST NAME: PALMETTO ENVIRONMENTAL Cell Level Grid ' 15. Special Handling Instructions and Additional Information :.ICI N .illitr ; •.',i.itr' rs Purchase Order 11 14027 EMERGENCY CONTACT/ PHONE NO.: 1-800-424-9300 24HR TOLL FREE 16. GENERATOR'S CERTIFICATE; I hereby certify that the above -described materials are not hazardous wastes as defined by CFR Part 261 or any applicable state law, have been fully and accurately described, classified and packaged and are in proper condition for transportation a ding to app I e regulations, Printed Name / f /t` Signature "On behalf oF' Mwuh Day i5:I]__r 17. Transporter 1( Acknowledgeme'ntt of9eceipt of Materials R A N Printed ame SI n re "�^ —�-- g Month Day Year 0 18. Transporter 2 Acknowledgement of Receipt of Material ---- i printed Name S nature � E Month Day Year 19. Certificate of Final Treaisnent/Disposal I certify, on behalf of the above listed treatment facility, that to the best of my knowledge, the above -described waste was managed In compliance with r appabJe laws gvlatlon permits and IIc ises on the dates listed above. all i t Q. Facllit wirer or O tor: Certiflcat i of receipt of non -hazardous materials d by this manifest, r r Prin ame Signature Mo tit y®r Whl a -TREATMENT, Sl'O AG . I POSAL FACILITY rnPV nI, , . r;rret rnn no . vsJ5. r' —•• • --'•' renew-vttvtHAluI nLcoPY Pink- FACILITY USE ONLY Gold- TRANSPORTER Ill COPY �► n� NON -HAZARDOUS MANIFEST NON -HAZARDOUS MANIFEST 1, Generator's US EPA ID No. Manifest Doc No, .. . iii'• ..�c Z, Page 1 of 3. Generator's Meiling Address; P,rWi Cpf►�t �°'4( Generator's Site Address (ualNwereuunmaHlntl: WELD COUNTY GOVERNMENT A. Manifest NumTF106 WMNA 155 % jr- 5.� y • 6 1113 H STREET li, State Generator's ID iJ�Cf' t� $'0 � GREELEY, CO 80631 4. Generator's Phone 303-825-8117 S. Tran orter 1 Company Name 6. US EPA ID Number iY1 ? �`IC�L>t :: ;!?' :' ; ,y' . .: _. C. . State 7ransporter's to • • •• . Jn•� f,; -I rr � ;: Wj 4o � 8 0. Transporters Phone ' 7. Transporter 2 Company Name 8. US EPA IO Number i. 4• . is ;•t: .rp; •yr: .i E. StateTransporter'sID • F, Transporter's Phone r : • r:,'•.. . ; r: '' 9. Designated Pacifty Name and Site Address 10, US EPA ID Number NORTH WELD LANDFILL G. State Facility ID ,f::;::. ; 40000 WELD COUNTY RD 25 ;; ;' , ' • ' . H. State Facility Phone 970-545-5015 AULT CO 80610 . .I ,,, ,, IL Description of Waste Materials contatiars a Taal 14. unit G N• TYP_ Qaanuty wt4vol. 1. Mbsc,Commank E a. NON REGULATED SOLID —EXCLUDED LIST CONTAMINATED N SOIL , YW R A WM Profile # 133126CO l ''', �' ;;: :IF ..: ,.r. Ali b. I',. i , 0 R WM Profile # +r I WM Proflfo Ir . III:'�•%'- J, ''•' WM Profile # ' r• .. ;.., I. Additional ''L.'; <,,.�• �� •l:�-•,. a Descriptions for Materials tfstedAboveuo- "' '" K. Disposal Location ACCT #: : N 10039 CUST NAME: PALMETTO ENVIRONMENTAL CeU Level Grid 15. Special Handling Instructions and Additional Information Purchase Order# 14027 EMERGENCY CONTACT/ PHONE NO.: 1-800-424-9300 24HR TOLL FREE 16, GENERATOR'S CERTIFICATE: I hereby certify that the above -described materials are not hazardous wastes as defined by CFR Part 261 or any applicable state law, have been fully and accurately described, dassiffed and pac1caed and are in proper condition for transportation ing to a (cable regulations. Printed Name Signature On behalf of" W011 Day Year 17. Transporter 1 Acknowledgement eceipt of Materials T a n P tod Name A7 th t1eY Y 18, Transporter 2 Adtnowledgernen of eceipt of Materials 7'' FI J4iiiEi i Printed Name Signature �. IrbnU, Day Year J . 19, Certificate of Final Treatment/Disposal A I certify, on behalf of the above listed treatment facility, that to the best of my knowledge, the above -described waste was managed in compliance with all ° applicable laws, regulations, permits and licenses on the dates listed above. 20. Facility Owner or Operator. Certification of receipt of non -hazardous materials cove .b s manifest. v d e i/ ^ A Signature _ M Y ' u. aw ear A hlFn..TRRATRAriwr mDA— I Ln ec �vrT Yellow- GENERATOR RrCOPY Pink- FACILITY USE ONLY Gold -TRANSPORTER #1 COPY , ►x NON -HAZARDOUS wnsre rougnrgqamgror MANIFEST 1, Generator's US EPA ID No. Manifest Doc No, NON -HAZARDOUS MANIFEST 2, Page 1 of 3. Generator's Mai Address: A Generator's Site Address prdIIM nit,,, nullingi, ' iSfyjYi Q £ w' -r lYtGr4 WELD COUNTY GOVERNMENT A. Manifest Number 10615520 l WMNA 1113 H STREET -1 j �, GREELEY, CO 80631 6, State Generator's ID 4. Generator's Phone 303.825-8117 5. Transporter I Company Name 6. US EPA ID Number t)r. cup. r ;:i;; ;! +t/Ol iy ,; C, State Transporter's l0 7. Transporter 2 Company Name 8. US EPA ID Number D. Transporter's Phone : r . w :7' i'}' • „=a' .. ,;, ; ,,: . dl r.: ' P,: . E. State Transporter's ID i • 9. Designated Faculty Name and Site Address 10. US EPA ID Number FTransporter's Phone . : v : •:, ; ` >:; = i NORTH WELD LANDFILL :=: : WELDCOUNTY RD 25 t ;!::: •,i;:: State Faculty l0 ,r:40000 970-545-5015 j15tath1tt00eG. `y'. ';Iv •' ;; I"'• :� isi:. .•. 1S!'1' I'�;i 'Y'ti. !:I"• >a '.�f1 :': ,a.a .4.. •^s ,. '. :r.. ir.:• art.. �;:��u'.' l.•i J. •'�' 11. Description of Waste Materials 12, ca,tainars .. 'f,i.,.. :`:,�:' ':I a :S:I .. s3.Tatai 54. unit G No. Type E a. NON REGULATED SOLID-.RXCLUDED UST CONTAMINATED quantity wt.JVoL I. Misc. C01n,Ylants N SOIL i•i:�. .' s: t 41. � [fie+. R WM Profile # 133126CQ i „ia. A ti, - ;fr.'+... . . ,l!j' li. ;i,. b. ..''.i T ., 0 R WM Profile # is : i ;'... i,. 41 r WM Profile fit .Is �/;" ... bi' ,.. ,WMProfile# :'a ` . : a..:;.:I J. Additional Descriptions far Materials Listed Above K, Disposal Location ACCT# : N 10039 CUST NAME: PALMETTO ENVIRONMENTAL Cell Level Grid IS. Special Handling Instructions and Additional Information Purchase Order # 14027 EMERGENCY CONTACT/ PHONE NO.! 1-800-424-9300 24HR TOLL FREE 16. GENERATOR'S CERTIFICATE: I hereby certify that the above -described materials are not hazardous wastes as defined by CFR Part 261 or any applicable state law, have been fully accurately described, classified and packaged and are in proper condition for transportation ac ding to appli and ble regulations. Printed Name �'? r D Signature "On behalf of Day Yaar r ]•7. Transporter 1 Acknowiedgemmn of Recef t of Materials n P ame S1 Ire art th oay Tear n 18. Transporter 2 Acknowledgement of Receipt of Materials T Printed Name Signature c Man% say Year 19, Certificate of Final Treatment/0lsposal n i certify, on behalf of the above listed treatment facility, that to the best of my knowledge, the above -described waste was managed In compliance applicable laws, regulations, permits and licenses on the dates listed above, with all 20. Facility Owner or Operator: Certification of receipt of non -hazardous n rla vered by this manifest. Y to ame� f _ Signs e rv, fr/%p M Pay Yaar y[' White -TREATMENT, STORAGE, DISPOSAL FACILITY COPY m. taco , on rno m ,-', — . r Cnuw- ucncrc%l VK WJ GUPY Pink- FACILITY USE ONLY Gold- TRANSPORTER #1 COPY ZO&T/ ■•T• u@ NON -HAZARDOUS MANIFEST 1. Generator's US EPA ID No, Manifest Doc No. NON -HAZARDOUS MANIFEST 2, Page 1 of {3.GGeneret 'aMailing Address: { Generator's Site Address lugifferentthanmallCna fjl ' 1 WELD COUNTY GOVERNMENT A. Manifest Number 10615521 �t�j?3 i h iJl�RtntlrtiG , '( F.� "� 1113 H STREET WMNA ,yjlGREELEY, CO 80631 a. State Generator's ID enerator'(Phone 303-825-8117 n)io�rter i ompanyName 6. US EPA ID Number r;:: •:-. : C State Transporter's ID : , w �TCr�f�►i� k . I ' ::.r".I D. Transporter's Phone •; , : ;r 7, Transporter 2 Company Nam 8. US EPA ID Number ;;�d• ,rr.•;:,r Irr ••-. E. State Transporter'siD ��•. 'i 9, Designated FacRRy Name and Site AddressNumber 10, US�}EPA ID N umber F. Transporter's Phone I . r ,p,�. � NORTH WELD LANDFILL ;•r• .:�4: G. State Facility ID .;t, 40000 WELD COUNTY RD 25 :' '1 •' H H. State Facility Phone 970-545-5015 AULT CO 80610 ••.. li!b• yr= rf:: ,. 1L Description of Waste Materials I11, con alnera 13• Thal 14. Unit G a. NON REGULATED SOLID —EXCLUDED UST CONTAMINATE D No, Type quantity wt./vol. I, fte.Cornments SOIL WM Profile g 133126C0 a "rr. aF _7__'u ; b . ., ;; • WM Profile# ;r, ' ______________________ —I 2r:,? Cur A. :t, ............................... d. , . . , .. WMProfile# '4' ; r', f' ,.I fir J. Additional Descriptions for Materials Listed Above K, Disposal Location . sat: ACCT # ; N 10039 CUST NAME: PALMETTO ENVIRONMENTAL Cell LeveIj Grid IS. Snariat Nan.aln„ Inca.,,.-w...,......a n.aan;__.r ,.-s_..e__ Purchase Order # 14027 EMERGENCY CONTACT/ PHONE NO.; 1-800-424-9300 24H R TOLL FREE 16. GENERATOR'S CERTIFICATE: I hereby certify that the above -described materials are not haxardotu wastes as defined by CFR Part 261 or any applicable state law, have been fully and aceurataly described, classified and packaged and are Inproper condition fur transportation actor Ing to ep cable regulations. Signature "On behalf of" Printed Name rsv Month Dap �Y r 17. Transporter 1 Acknowledgement o ecelpt of Materials NPlfnted Name Signature ,, s Month Day 0 18. Transporter 2 Acknowledgement of Receipt of Materials T nted Na a Slgnatur e Month pay 1 r.> . c.5 rte, - 17 19. CertifIcatn of Final Ire ant/Disposal n I certify, on behalf a above isted treatment facility, that to the best of my knowledge, the above -described waste was mans ed in compliance with g applicable la egulatlons, mats and licenses on the dates listed above, all 20. Fadllt r or or: Certficatlo • receipt of non -hazardous materials co yth smaMfest. Prin me Signature Mon flay Wh e -TREATMENT, STORA E, DISPOSAL FACILITY COPY Blue -GE ATOR #2 COPY Yellow GENERATOR 1 COPY Pink- FACILITY USE ONLY Gold- TRANSPORTER #1 COPY / _ Year Year ■ A& /--AF__A W V NON -HAZARDOUS MANIFEST NON -HAZARDOUS MANIFEST 1. Generator's US EPA ID No. Manifest Doc No. 2. Page 1 of 3 Generator's Mailing Address: ' 6yow4n f"Vi1( Generator's Site Address Qrdlaerant thae rmili Klr WELD COUNTY GOVERNMENT A. Manifest Number 10615522 t'�+2 �+ lor* X 1've_ " 1113 F! STREET WMNA B. State Generator's ID 'to 3i)≥ -44 GREELEY, CO 80631 •:. 4. Generator's Phone 303-825-8117 S. Trens�irter Z. -C tnganY Name 6. US EPA ID Number !~ ` ;". ; 1, f C. State Transporter's l ��eSii .I. ID ,i `r I R.Transporter'sPhnne �.• .•I,.-1 .. , s'i ; ':: • ; 7. Transporter 2 Compan Name 8. US EPA ID Number : ,, .rt r,i . , I E. E. StateTransporter's ID is F,Trans orter'sPhone ,rai t:i'. ;'+ 9. Designated Facility Name and Site Address 10. US EPA ID Number NORTH WELD LANDFILL ,•,: G. State Facilltyil = ;i •r, t,; -: 40000 WELD COUNTY RD 25 i I Ir H. State Facility Phone 970-545-5015 AULT CO 80610 :. I:,r,;;• • " To;. •,.r r;li .ij•i: �I;.-. _, 1iij •.;� a' - ,•.d�3„ .:p, ,,, '•,y' s. 's.!;1" 11. Description of Waste Materials 1ZCantaYters 13, Total 14, unit • G aa• TYPe Qua I. Mlec, Conlrrl0rH9 E a.. NON REGULATED SOLID — EXCLUDED UST CONTAMINATED N SOIL d� r E R WM Profile# 133126C0 I;'F i- T b. R WM Protile # .. I .r, I I . WMProfile# i .� '. ;K:'' y,>• 4Y1e. d. 5:1. .. WMProfile # :,.`. F,, ' • •'. '. @Ii`.. ' '". J. Additional Descriptions for Materials Listed Above K, Disposal Location ACCT#: N 10039 CUSTNAME, PALMETTO ENVIRONMENTAL Ce0 Level Grid 15. Special Handling Instructions and Additional Information Purchase Order# 14027 EMERGENCY CONTACT/ PHONE NO.: 1-800-424-9300 24HR TOLL FREE 16. GENERATOR'S CERTIFICATE; I hereby certify that the above -described materials are not hazardous wastes as defined by CFR Part 261 or any applicable state law, have been fully and accurately described, classified and packaged and are in propercorsditlon for transportation accords to applkabl egulotions. Printed Name t Signature "On behalf of" Mmtth Day Year T 17. Transporter 1 Acknowledgement of eceipt of Materials ' R n n d N Sl re Ye u 18. Transporter 2 Acknowledgement of Recerpt of Materials r Printed Name Sfgrtattre Month Day Year R 19, Certificate of Fin eatrnent/Disposal n I certify, an b f of the hove listed treatment facility, that to the best of my knowledge, the above -described waste was managed In compliance with all appllcabl s, r ula ns, permits and licenses on the dates listed above. 20. F t r Operator ertlfIcajin of receipt of non -hazardous materials covered is manifest, 1T P ted Na Signature _ Man vay Year Ithim.. TDCAraatnrr crnn, c n YeaoW-GENERATOli1COPY Pink- FAGLWFY USE ONLY Gold- TRANSPORTER #1 COPY /' _ /�//n WWVZ�-�NON-HAZARDOUS MAN IJT IFEST z. generator's u5 EPA ID No. Manifest Doc No. NON -HAZARDOUS MANIFEST 2. Page 1 of S. Generator's Mailing Address: Generator's Site Address u tdlaare„ t then mailing); WELD COUNTY A. Manifest Number 4}1`t"�Yf D,`"►nit: GOVERNMENT 10615524 (J�� 1113 H STREET WMNA B, state Generator's ID a✓•� • l� p o�•�t. 4 GREELEY, CO.80631 4. Generator's Phone 303-825-8117 .. ... 5 ThTrra`neporter ] C T inpanyName �y C 6' US EPA ID Number �:: ! I:! r i `" C. StateTra ortees iD i,: " ' O V D, Transporter's Phone ; 7. Transporter 2 Company Name B. US EPA ID Number ;: " r n:;' I .I!I E. State Transporter's ID r, F. Transporter's Phone : •! 9. Designated Facility Name and Site Address 10, US EPA ID Number e l?:°: • E , ;r`:: : s i'ii • r: ;"" • • . NORTH WELD LANDFILL G. State Faclity ID tu:, , : ;, 40000 WELD COUNTY RD 25 r!!' AULT CO 80510 H. State Facility Phone 970-S45,S015 ..�„ - : �. ;i` i "� 11. Description of Waste Materials 1a. Caotalnen 13• Total 1A. Unk No. ivpe Quantity wt. Nol. I. Misc comments a, NON REGULATED SOLID-. EXCLUDED UST CONTAMINATED I SOIL U. WM Profile # 133126CO ;;i;r;i • WM Profile # : ;. i 1 I r a,,• t.., .,..'I4.-.,.. r•. :.h. WM Profile If ; ! i:n•• ! ?' nr.` '}^ Ir .' d ! ! :; is : _yJgr, 11r WM Profile # : e „ i ;. i . �; 1?' : 'i $' I. Additional Descriptions for Materials Listed Above K. Disposal Location ACCT# : N 10039 COST NAME: PALMETTO ENVIRONMENTAL Cell Level Grid Purchase Order# 14027 EMERGENCYCONTACT/ PHONE NO.: 1-800-424.9300 24HR TOLL FREE 16. GENERATOR'S CERTIFICATE; I hereby certify that the above -described materials are not hazardous wastes as defined by CFR Part 261 or any applicable state law, have been fully and accurately described, classified and packaged and are in proper condition fortransportatlon accoring to apI1cable regulations. Printed Name ('f. — ._ Signature"On behalfof ,,,••.,,,, T 17. Tr porter 1 Acknowledgement oFRecelpt of Materials `'— r ro Plf d Na Sigma ure Mo- I nth �"' � •--�•. Dal' 0 18. Transporter 2 Acknowledgement of Receipt of Materials Printed Name 51 attire r � Montlr nay 19. Certificate offinal x nt/Disposal r I certify, on tae) if o' t"he ebov listed treatment facility, that to the best of my knowledge, the above -described waste was managed in compliance with all applicable la) latio rmits and licenses on the dates listed above. L 2O.Fgw r Ocra7Certlfln of receipt of non-ha2ardotts materials coy hIs manifest Y FM Najaf Signature M rak, n — ENT, STORAGE, DISPOSAL FACILITY COPY Blue- GENERATOR 42 COPY Yellow- GI Pink- FACIUTY USE ONLY Gold -TRANSPORTER 91 COPY o / 6 t - NON -HAZARDOUS US MANIFEST 1, Generator's US CPA ID No. Manifest Doc No, NON -HAZARDOUS MANIFEST 2, Page 1 of 3. Generator's Mailing Address: Generator's Site Address (udaterentthan maainsl A. Manifest Number WELD COUNTY GOVERNMENT 10615523 44'5 work. $+r -1 1113 H STREET WMNA GREELEY, CO 80631 B. State Generator's IDb�ti.(4 • , ' 4. Generator's Phone 303-825-8117 US EPA ID Number ranspgrter 1 Ca panlKa F �+ . • :, `:. " State C, State Transporter's ID I 7. Transporter 2 Company Name g US EPA lD Number D, Trans rter's Phone 1: TiTT : ::: r I: I : r,a. E, State Transporter's ID ,... 9. Designated Facility Name and Site Address 1U. US EPA JD Number F.Transporter's Phone i i'• , .. • , ..:. NORTH WELD LANDFILL "': 40000 WELD COUNTY RD 25 E,• G. State Facility ID AULT CO 80610 II H. State Facility Phone 970-545-5015 'fit °•. :„ • •. : .�' ::x 'ii:i, i, i;ir, rt . ,i:•. ;.'qtc:' rY its'' .: f 11. Description of Waste Materials 12 Contslners 1s. Total 14. itnit G Na, Type E a, NON REGULATED SOLID — EXCLUDED UST CONTANMINATEfI) quanlltY WtNal• L MlsaClomments N SOIL t' . * �• 1i R WM Profile # 133126CO ;! ;: T ,... :.' R 1NM profile # :a ,I .. r ,.: :;.' WMProflle# I•d!'Ir :I: i' :, , WMProfile# 1r:' Jr I ;, 1.' ::L:: :.:. J. Additional Descriptions for Materials Listed Above t K. Disposal cati Location ACCT# : N 10039 CUST NAME: PALMETTO ENVIRONMENTAL Arid Fherebycertffy Handling Instructions and Additional Information Order if 14027 EMERGENCY CONTACT/ PHONE NO.: 1-800-424-9300 24HRTOLL FREE OR'S CERTIFICATE; I y that the above -described materials are not hazardous wastes as defined by CFR Part 261 or any applicable state law, have been fully and cribed, classified and packaged and are In roper condition font ransportation or ng to applicab! egulations, Printed Name Signature "On behalf of" Mmih Gay 17. Transporter I Acknowledgement of R celpt of Materials A Pri tee me , l Si' 4 M th aey UJ p 18, Transporter 2 Acknowledgement of Receipt of Materials T Printed Name S nature e � Month pay 19. Certificate of Final Treatment/Dlsposal cI certify, on boa oft above listed treatment facility, that to the best of my knowledge, the above -described waste was managed in compliance with all l applicable s, reguratl ns, rmlts and licenses on the dates listed above, 2Q. Fa Owner • perat : CertlFl tionofrecelptofnan-haaardousmaterla v redbythism.olfest. ry P d l Signature LrtI, STORAGE, DISPOSAL FACILITY COPY Blue- ERATOR #2 COPY Yellow- GENERATOR 1 Pink- FACILITY USE ONLY Gold- TRANSPORTER #1 COPY J1 �O ,4t✓1' Mrr-tr-� NON -HAZARDOUS MANIFEST W !. Generator's US EPA ID No. Manifest Doc No. 2. Page 1 of NON -HAZARDOUS MANIFEST 3, Generator's Mailing Address: Generator's Site Address Itf dttfere,t than mollhWi A. Manifest Number WELD COUNTY GOVERNMENT WMNA 10615560 1113 H STREET B. State Generator's ID GREELEY, CO 80631 4. Generator's Phone 303-825-8117 5. Transporter 1 Comjseny Name 7'! CN,7 »,/ 6. US EPA ID Number K,a ;; " 'i C. State Transporter's 1D � ! .:: • •, •i • fx_ i My� � D.Transporter's Phone . r,. ; I .,n= f9r 7, Transporter 2 Company Nama S. US EPA.ID Number j+"' 's ..;t+• P :4 c ij . l,i F . E. State Transporter's ID :: F, Transporter's Phone ii.:, .:, :, •,.; 9, Designated Facility Name and Site Address !0. US EPA ID Number >+-' :: +!• . 3 ;!r_.: •. NORTH WELD LANDFILL G. State Faclity ID !.'"; 40000 WELD COUNTY RD 25 '' ` i'' ' + '' H. State Facility Phone 97O -545-5O15 AULT CO 80610 p ii; `,j;.e. :EI It'ii :; • `?q;., 1 , i•i�t . .; '•:'.' •' ;.�,• •, v 4 �' t'".N.' .,,i• ;i .:h':.' N, 4 11. Descrlptkm of Waste Materials 12. coraelneis 13.Tot5 14. lint G No. lypn QuarRky wt./Vd. I. Mfsc.Commmnks a. NON REGULATED SOLID — EXCLUDED UST CONTAMINATED ' N SOIL ; „ !. ht , t R A WM Profile # 133126C0 b, , : OA., './ . .: WM Profile # :.i: : . ,; t:; • ��i`'• WM# Profile a,•, l r.:• g,, • .N . !i•. '/l'• .,, .i WMProfile# 'vVI1!. `:IEI aryl_• :+i;` ;, it ,N .. r=: :,1I. Additional Descriptions for Materials Listed Above tion ACCT #: N 10039 OUST NAME: PALMETTO ENVIRONMENTAL .p,.. Level 15, Special Handling Instructions and Additional Information ...q., Ili Purchase Order# 14D27 EMERGENCY CONTACT/PHONENO.: 1-8OO-424-93OO 24HR TOLL FREE 16. GENERATOR'SCERTIFICATE: I hereby certify that the above -described materials are not hazardous wastes as defined by CFR Part 261 or any applicable state law, have been fully and accurately described, classified and packs ad and are in proper condition for transportation ngto a licable regulations. Printed Nama 1 l ��` "./ Signature "On behalf o Month DaY Year f 2r r 17. Transporter 1 Acknowledgement of Receipt of Materials sP led Na Slgnalu Month oay Year 0 113. Transporter 2 Acknowledgement of Receipt of Materials Printed Name Signature Month oay Year 19. Certificate of Final Treatment/Disposal a I certify, on behalf of the above listed treatment facility, that to the best of my knowledge, the above -described waste was managed in compliance with all applicable laws, regulations, permits and licenses on the dates listed above. 20. Facility Owner orOperator Certification of receipt of non -hazardous mate s covered by this manifest. Y red ma Slgnat re lh a Year 1A1 4w The eTalCA14• [• r-- -------- -... ,..... .•.--------- rrti..vr, Turruw- urwtiie!UK#1CQPY Pink- FACILITY USE ONLY Gold- TRANSPORTER #1 COPY J WASTE NWNAOEMENT� NON -HAZARDOUS MANIFEST NON -HAZARDOUS MANIFEST 1. Generator's US EPA ID No. Manifest Doc No, 2. Page 1 of 3. Generator's Mailing Address: 4. Generator's Phone 303-825-8117 Generator's Site Address (if difnent than mailing): WELD COUNTY GOVERNMENT 1113 H STREET GREELEY, CO 80631 A. Manifest Number WMNA 10615561 B. State Generator's ID 5. Transporter 1 Company Name '2 . �-7� t 5 fN It. .-i ' ' ' "U 6. US EPA ID Number C. State Transporter's ID D. Transporter's Phone 7. Transporter 2 Company Name 8. US EPA ID Number E. State Transporter's ID F. Transporter's Phone 9. Designated Facility Name and Site Address NORTH WELD LANDFILL 40000 WELD COUNTY RD 25 AULT CO 80610 10. US EPA ID Number G. State Facility ID H. State Facility Phone 970-545-5015 4 G 11. Description of Waste Materials 12. Containers 13. Total Quantity 14, unit Wt.tvol. t. Misc. Comments No. Type E N E R a. NON REGULATED SOLID —EXCLUDED UST CONTAMINATED SOIL WM Profile # 133126CO //� / V (rr T T 0 R b. WM Profile # C. WM Profile # d. WM Profile # II J. Additional Descriptions for Materials Listed Above ACCT St : N 10039 CUST NAME: PALMETTO ENVIRONMENTAL K. Disposal Location Cell Level Grid 15. Special Handling Instructions and Additional Information Purchase Order # 14027 EMERGENCY CONTACT / PHONE NO.: 1-800-424-9300 24HR TOLL FREE 16. GENERATOR'S CERTIFICATE: I hereby certify that the above -described materials are not hazardous wastes as defined by CFR Part 261 or any applicable state law, have been fully and accurately described, classified and packaged and are in proper condition for transportation according to applicable regulations. Printed Name. Signature "On behalf of— -> Day year t 17. Transporter 1 Acknowledgement of Receipt of Materials Printed Signature Mp m oay Year 0 18. Transporter 2 Acknowledgement of Receipt of Materials Printed Name Signature btonth Dxy Year i 19. Certificate of Final Treatment/Disposal I certify, on behalf of the above listed treatment facility, that to the best of my knowledge, the above -described waste was managed in compliance with all applicable laws, regulations, permits and licenses on the dates listed above. 20. Facility Owner or Operator: Certification of receipt of non -hazardous ma vials covered by this manifest. Anted ame J tp 4]i av Yexr vnr. F�rwML F - L11 t'..vrr ,me- UCNLKAJUK rfL IUYY Yellow- GENERATOR Ill COPY Pink- FACILITY USE ONLY Gold- TRANSPORTER U1 COPY NON -HAZARDOUS MANIFEST 1. Generator's US EPA ID No. Manifest Doc No. 2. Page 1 of NON -HAZARDOUS MANIFEST 3. Generator's Mailing Address: Generator's Site Address Dfdlff.antthaamRlnndl A. Manifest Number WELD COUNTY GOVERNMENT WMNA 10615559 1113 H STREET S. State Generator's ID GREELEY, CO 80631 4. Generator's Phone 303-825-8117 5Jransporter i Com tiny Namee 6. US EPA ID Number ,.. ;:::' • : ....1 ,- ":: "71dt(s,.� :. ,i"r4 fJ -- .: i �;r:, CStateTransporter'110 ,.- r:•rt ✓.i.,l' . ��SW(b D. Transporters Phone i:'. i:; ..., •. �r,.•.,. 7. Transporter 2 Company Name 8. US EPA ID Number +`'`j. ;: r r, ,ti•:•: E. State Transporter'sID .r.' . P: . itu F.Transporter'sPhone 9. Designated Facility Name and She Address 10. US EPA ID Number "+� ., NORTH WELD LANDFILL G. State FaclNtylD ..• � • . F -r.. .., :'-' 40000 WELD COUNTY RD 25 : :1 ; _: H. State Facility Phone 970-545-5015 AULT CO 80610 11. Description of Waste Materials 1z,Golttalnars 13, Tote) l4. Ur,R G nto. Type Quantity wt/vol: n• Mhc. comments E a. NON REGULATED SOLID— EXCLUDED UST CONTAMINATED N SOIL it,. •Zt A WM Proflle # 133126C0 T , .t a I.'�• :1':l.. R WM Profile# I;. yi' is xH=:1 r.Yt '' ;rte?•' Ff... aw.. WMProfile U iII. d.:,+; WMProfile# t,f.; ;.,_. . ; M1'r': ,.: e,•e; .' J . Additional Descriptions for Materiels Listed Above K. Disposal Locatiati on Location ACCT 9 : N 10039 COST NAME: PALMETTO ENVIRONMENTAL Cell Level Grid 15. Special Handling Instructions and Additional Information Purchase Order# 14027 EMERGENCY CONTACT/PFIONEM : 1-800-424-9300 24HR TOLL FREE 16. GENERATOR'S CERTIFICATE: I hereby certify that the above -described materials are not hazardous wastes as dellned by CFR Part 251. or any applicable state law, have been fully and accurate( described, classified and packaged and are in proper condition fortransportatlon according to applicable regulations, Printed Name Signature "On behalf or Month oay Year r 17. Transporter I Acknowledgement of Receipt of Materials A a Printed Na �} '•'T� v Signature Month ony Year n 18. Transporter 2 Acknowledgement of Receipt of Materials R Printed Name Signature Monte oay Year 19, Certificate of Final Treatment/Disposal A I certify, on behalf of the above listed treatment facility, that to the best of my knowledge, the above -described waste was managed In compliance with all applicable laws, regulations, permits and licenses on the dates listed above. i 20. Fadilty Owner or Operator: Certification of receipt of non -hazardous materl verod by this ma nil Y Y nted me ` Sig ±ThF7, v r vnrsvc, vurvxw. r,x.tr tl s wr r Clue- GEN6KA I UK PL I:UPY Yellow- GENERATOR #1 COPY Pink- FACILITY USE ONLY Gold- TRANSPORTER #1 COPY e 1P " NON -HAZARDOUS MANIFEST YYASTe MANA6EMENTa NON -HAZARDOUS MANIFEST 1. Generator's US EPA ID No. Manifest Doc No. 2. Page 1 of 3. Generator's Mailing Address: Generator's Site Address (Irdifferent than tnaain5l, A. Manifest Number WELD COUNTY GOVERNMENT 1113 H STREET GREELEY, CO 80631 WMNA 10615558 B. State Generator's ID 4. Generator's Phone 303-825-8117 5. Transporter 1 Company Name is 4M G o 1 —. �. z7-tl JC 6. US EPA ID Number C. State Transporter's ID D. Transporter's Phone 7. Transporter 2 Company Name 8. US EPA ID Number E. State Transporter's ID F. Transporter's Phone 9. Designated Facility Name and Site Address 10. US EPA ID Number NORTH WELD LANDFILL 40000 WELD COUNTY RD 25 AULT CO 80610 G. State Facility ID H. State Facility Phone 970-545-5015 G 11. Description of Waste Materials ra- containers 13. Total Quantity 14. Unit wt.Itrat. t. Miss. Cammenss Na. TYPe E a. NON REGULATED SOLID — EXCLUDED UST CONTAMINATED N SOIL J L_ E RR WM Profile # 133126CO O I R WM Profile # ___ ___ ___ ____ WM Profile # d. WM Profile # J. Additional Descriptions for Materials Listed Above K. Disposal Location ACCT #: N 10039 CUST NAME: PALMETTO ENVIRONMENTAL Cell Level Grid 15. Special Handling Instructions and Additional Information Purchase Order 0 14O27 EMERGENCY CONTACT / PHONE NO.: 1-8OO-424-93OO 24HR TOLL FREE 16. GENERATOR'S CERTIFICATE: I hereby certify that the above -described materials are not hazardous wastes as defined by CFR Part 261 or any applicable state law, have been fully and accurately described, classified and packaged and are in proper condition for transportation according to applicable regulations. r Print rp j Signature�Aa-behaifci 1( Wes, 17. Transporter I Acknowledgement of Receipt of Materials A Prin ed,N e � l Signature Month Day Year 18. Transporter 2 Acknowledgement of Receipt of Materials T fl Printed Name Signature Mavth Day year 19. Certificate of Final Treatment/Disposal F A t I certify, on behalf of the above listed treatment facility, that to the best of my knowledge, the above -described waste was managed in compliance with all applicable laws, regulations, permits and licenses on the dates listed above. 20. Facility Owner or Operator: Certification of receipt of non -hazardous terials covered by this manife f, r r ted N e '. Sig re ,.-' `�-1'7'1 ►" I a-^'" `"'m. u�..- mm, � H rth Day Year r D fArtiita-Ta FeTaeGntT CTnaAr7C MfOn[n, cnn, iry - - ..--• -•- --• -- • • -, u E- cnn, vr. nc i.vr r Yellow- GENERATOR NrCOPY Pink- FACILITY USE ONLY Gold- TRANSPORTER lt1 COPY U r T1/-1 MlAiTa NON -HAZARDOUS MANIFEST NnAIYAAatlYrCMY NON-HAiARDOUS MANIFEST 1. Generator's US EPA ID No. Manifest Doc No, - 2. Page 1 of 3. Generator's Mottling Address Generator's Site Address pfdige entuwn ma111nr1: A. Manifest Number WELD COUNTY GOVi:RNMENT WMNA 10615525 1113 H STREET B. State Generator's ID GREELEY, CO 80631 4. Generator's Phone 303-825-8117 S,an orterl,Gat 6. US EPA ID Number .:, ' r ¢ dot f • C. State Trans rtar's ID 7. Transporter 2 Company Name g, U S EPA lb Ntmrber D. Trans otter's Phone T.,. ... c . ; r:. . -+•:: "ev : .t r ; : 1. E. State Transporter's ID ri:, ; 9, Designated Facility Name and Site Address 10, USEPA ID Number F. Transporter's Phone i;rrr °T.' ; /p; NORTH WELD LANDFILL ;N'i'` 40000 WELD COUNTY RD 25 ,11 G. State Facility ID r AULT CO 80610 H7O- H. State Facility Phone 970-545-5015 _ r ,, 11. Description of Waste Moterinls ' tz.Contalners 13.rotal 1a. Unit G No. Type QuentRy WL/Vd. Mke.Cminents E a. NON REGULATED SOLID — LXCLUDED UST CONTAMINATED NSOIL N. I' . r'Jv`+� R WM Profile A 133126C0 �' r ,�. WM Profile A ; I ! ' I i 1 :i4ti:; i AMA :.�n.`l: is yy .. �lll:�• �M` yv�' :. •j(:I: WM Profile # i WMProflell ':' ..'?:1. ' ii,:•• . .4'. :'• :.:. i,..� , 11' ' •fir' µ , •�'�"'° J. Additional Descrlptbns for Materials Listed Above oil K. Disposal Location ' ACCT# : N 10039 CUST NAME: PALMETTO ENVIRONMENTAL Cell Level Gild --."Y`•••`"•••,••..+....a...aa.u,.�iy,la Nina /luu.Nuira11r IIt mil[lull Purchase Order # 14027 EMERGENCY CONTACT/ PHONE NO,; 1-800-424.9300 241 -SR TOLL FREE 16. GENERATOR'S CERTIFICATE! I hereby certify that the above -described materials are not hazardous wastes as defined by CFR Part 261 or any applicable state law, have been fully and accurately desafbed, ciassifkd and packaged and are In proper condition for transportation according to applicable regulations. 2a signature "Ambehal� Month oay vase T 17. Transporter, i Adtnowledgernent of Receipt of Materials a a Pr Led Npme Signaler �� N 1 �"�^�t MOMb Day Year s rC 18. Transporter 2 Acknowledgement of Receipt of Materials Printed Name Slghature Month Day Year n 19. Certificate of Final TreatmentjDLsposalii n i certify, on behalf of the above listed treatment facfflty, that to the best of my knowledge, the above -described waste was managed in compliance with all c applicable laws regulations, permits and licenses on the dates listed above. i L 20. F a c il i t yO�wner or Operator: Certification of receipt of non -hazardous materials red by this manifest. in Y a P tabNi�a�rte if w I Slgn e- _ i r6 •a..,. TREATMENT, STORAGE, DISPOSAL FACILITY COPY Blue• GENERATOR #2 COPY Yellow- GENERATOR #1 COPY Pink- FACILITY USE ONLY Gold- TRANSPORTER #1 COPY / NON -HAZARDOUS MANIFEST NON -HAZARDOUS MANIFEST 1. Generator's US EPA ID No. Manifest Doc No. 2. Page 1 of 3. Generator's Mailing Address: Generator's Site Address (if different than mailing): A. Manifest Number WELD COUNTY GOVERNMENT 10615526 WMNA 1113 H STREET B. State Generator's ID GREELEY, CO 80631 4. Generator's Phone 303-825-8117 SI Sransporter 1 Company Name 6. US EPA ID Number 1 S ( J , ' o I C. State Transporter's ID D. Transporter's Phone 7. Transporter 2 Company Name 8. US EPA ID Number E. State Transporter's ID F. Transporter's Phone 9. Designated Facility Name and Site Address 10. US EPA ID Number NORTH WELD LANDFILL G. State Facility ID 40000 WELD COUNTY RD 25 H. State Facility Phone 970-545-5015 AULT CO 80610 11. Description of Waste Materials 12. Containers 13. Total 14. Unit van. type Ouanety WI./Vol. Misc. Comments a. NON REGULATED SOLID— EXCLUDED UST CONTAMINATED N SOIL l r� E R WM Profile # 133126CO b. T O R WM Profile # C. j WM Profile # WM Profile # J. Additional Descriptions for Materials Listed Above K. Disposal Location ACCT#: N 10039 CUST NAME: PALMETTO ENVIRONMENTAL Cell Level Grid 15, Special Handling Instructions and Additional Information Purchase Order It 14027 EMERGENCY CONTACT / PHONE NO.: 1-800-424-9300 24HR TOLL FREE 16. GENERATOR'S CERTIFICATE: I hereby certify that the above -described materials are not hazardous wastes as defined by CFR Part 261 or any applicable state law, have been fully and accurately described, classified and packaged and are in proper condition for transportation according to applicable regulations. Printed Name -- I---- / r .�. � L Signature "On behalf-oP--"o Month Day Tea j 4 t r rt 17. Transporter 1 Acknowledgement of Receipt of Materials A Printedll Signature �/ ;/, Mrn,th Day Year 0 18. Transporter 2 Acknowle gement of Receipt of Materials Printed Name Signature Month Day Year 19. Certificate of Final Treatment/Disposal A I certify, on behalf of the above listed treatment facility, that to the best of my knowledge, the above -described waste was managed in compliance with all applicable laws, regulations, permits and licenses on the dates listed above. 20. Facility Owner or Operator: Certj -cation of receipt of non -hazardous aterialo red by this manifest. r Printed N ti Signat ,e -7H car Whit.. TRFATMCArr CTnn Ar17 n COnCAI [nru iry rnnv ..r _.-�..�... �.....--- -• r, o+ue- UCI Ctt5I UM RL COPY Yellow- GENERATOR #1 COPY Pink- FACILITY USE ONLY Gold- TRANSPORTER #1 COPY 7ULt0 ■Mr -An NON -HAZARDOUS MANIFEST NON -HAZARDOUS MANIFEST 1. Generator's US EPA ID No. Manifest Doc No. 2. Page 1 of 3. Generator's Mailing Address: Generator's Site Address Indifferent than malkn�l: A. Manifest Number WELD COUNTY GOVERNMENT 10615527 1113 H STREET WMNA B. State Generator's ID GREELEY, CO 80631 4. Generator's Phone 303-825-8117 S. Transporter 1 Company Name 6. US EPA ID Number f i L (` C. State Transporter's ID Y C'i � � r-<i. i�. t - , <c ` is < (C D. Transporter's Phone 7. Transporter 2 Company Name 8. US EPA ID Number E. State Transporter's ID 9. Designated Facility Name and Site Address 10. US EPA ID Number F. Transporter's Phone NORTH WELD LANDFILL G. State Facility ID 40000 WELD COUNTY RD 25 H. State Facility Phone 970-545-5015 AULT CO 80610 11. Description of Waste Materials 12. Containers 13. Total 14. Unit No. Type G Quantity WL/Vol. 1. Misc. comments E a. NON REGULATED SOLID —EXCLUDED UST CONTAMINATED N SOIL R WM Profile # 133126CO A b. T I0 R WM Profile U M I. WM Profile If WM Proflle # J. Additional Descriptions for Materials Listed Above K. Disposal Location ACCT #: N 10039 CUST NAME: PALMETTO ENVIRONMENTAL Cell Level Grid 15. Special Handling Instructions and Additional Information Purchase Order II 14027 EMERGENCY CONTACT/ PHONE NO.: 1-800-424-9300 24HR TOLL FREE 16. GENERATOR'S CERTIFICATE: I hereby certify that the above -described materials are not hazardous wastes as defined by CFR Part 261 or any applicable state law, have been fully and accurately described, classified and packaged and are in proper condition for transportation according to applicable regulations. Printed Name f� L,Signattr 0rrbehalf � '` Month Day Year T R 17. Transporter 1 Acknowledgement of Receipt of Materials a P " t Name $I r e Month Day Year a 18. Transporter 2 Acknowledgement of R eipt of Materials T Printed Name Si nature g E Month DaV Year r 19. Certificate of Final Treatment/Disposal I certify, on behalf of the above listed treatment facility, that to the best of my knowledge, the above -described waste was managed in compliance with all applicable laws, regulations, permits and licenses on the dates listed above. t 20. Facility Owner or Operator: Certification of receipt of non-hazardouk MP! vials covered by this nifest. ' Printed//Na �p r fii� ! i Signa s Mon io x (rear W ite-TREATMENT.STORAGE.DISPOSAi FArnrTvrnvv m.. r_cn,�oer o ^�., ', c <.vr r YetIow-tiENERATOR #I COPY Pink- FACILITY USE ONLY Gold- TRANSPORTER #1 COPY WASTE XA[ " NON -HAZARDOUS MANIFEST NON -HAZARDOUS MANIFEST 1. Generator's US EPA ID No. Manifest Doc No, 2. Page 101 3. Generator's Mailing Address: Generator's Site Address (itdinerent than mailing): A Manifest Number WELD COUNTY GOVERNMENT 10615528 WMNA 1113 H STREET 8. State Generator's ID GREELEY, CO 80631 4. Generator's Phone 303-825-8117 S. Transporter 1 Company Name 6. US EPA ID Number C. State Transporter's ID D. Transporter's Phone 7. Transporter 2 ompaay Name 8. US EPA ID Number E. State Transporter's ID F. Transporter's Phone 9. Designated Facility Name and Site Address 10. US EPA ID Number NORTH WELD LANDFILL G. State Facility ID 40000 WELD COUNTY RD 25 H. State Facility Phone 970-545-5015 AULT CO 80610 11. Description of Waste Materials 12. Containers 13. Total 14. Unit G No- Type Quantity wt./Vol. I. Misc. Comments E a. NON REGULATED SOLID — EXCLUDED UST CONTAMINATED N E SOIL t C�tl y R WM Profile # 133126CO IiJI Ab T 0 I R WM Profile If WM Profile if d. I I WM Profile N J. Additional Descriptions for Materials Listed Above K. Disposal Location ACCT if: N 10039 CUST NAME: PALMETTO ENVIRONMENTAL Cell 1Level Grid 15. Special Handling Instructions and Additional Information Purchase Order It 14027 EMERGENCY CONTACT/ PHONE NO.: 1-800-424-9300 24HR TOLL FREE 16. GENERATOR'S CERTIFICATE: I hereby certify that the above -described materials are not hazardous wastes as defined by CFR Part 261 or any applicable state law, have been fully and accurately described, classified and packaged and are in proper condition for transportation according to applicable regulations. Pr' Name �` Signature "On behalf of" /".,'- . C c, Month Uay Year T R 17. Transporter 1 Acknowledgement of Receipt of Materials ;i H Printed Name Signature ,- Mo tlh oay Year 18. Transporter 2 Acknowledgement of Receipt of Materials ePrinted R Name Signature Month oay year 19. Certificate of Final Treatment/Disposal I ` certify, on behalf of the above listed treatment facility, that to the best of my knowledge, the above -described waste ,as managed in compliance with all applicable laws, regulations, permits and licenses on the dates listed above. 20. Facility wner r Operator:(Certifica_tion��r�ceipt of non -hazardous m ryl overed by this manifest./ Y P n Name 4 / Signatu W ice- TREATM NT. cTnRACF nicpncni cnni iry rno +� ., �� ,, s.vr r Yellow- GENERATOR tfYtOPY Pink- FACILITY USE ONLY Gold- TRANSPORTER HI COPY \ WASTE MANAGEMENT NON -HAZARDOUS MANIFEST NON -HAZARDOUS MANIFEST 1. Generator's US EPA ID No, Manifest Doc No. 2. Page 1 of 3. Generator's Mailing Address: Generator's Site Address Ill dinemnt than mailing): A. Manifest Number Pal rn r? tLo £1w,troll r"&"t41 WELD COUNTY GOVERNMENT WMNA 10615555 LIcCl5 VoitK St -,L-& 1113 H STREET B. State Generator's ID D stn v&srr Co %0216 GREELEY, CO 80631 4. Generator's Phone 303-825-8117 5. Transporter 1 Company Name Tr Cup IrUCk.-rJ. Dc. 6. US EPA ID Number C. State Transporter's ID 37ao `i E.ie. k4 W41 W N`6 D. Transporter's Phone 1 Fre4ei'ui 7. Transporter 2 Company Name 8. US EPA ID Number E. State Transporter's ID 9. Designated Facility Name and Site Address 10. US•EPA ID Number F. Transporter's Phone NORTH WELD LANDFILL r G. State Facility ID 40000 WELD COUNTY RD 25 H. State Facility Phone 970-545-5015 AULT CO 80610 11. Description of Waste Materials 11. Containers 13. Total 14. unit No. Type G Quantity wt./Vol. I. Misc. Comments E a. NON REGULATED SOLID— EXCLUDED UST CONTAMINATED N SOIL q( 5 E R WM Profile fr 133126CO b. T O R WM Profile # WM Profile a d. I:, WM Profile N J. Additional Descriptions for Materials Listed Above ____ K. Disposal Location ACCT III : N 10039 CUST NAME: PALMETTO ENVIRONMENTAL Cell Level Grid 15. Special Handling Instructions and Additional Information Purchase Order U 14027 EMERGENCY CONTACT/ PHONE NO.: 1-800-424-9300 24HRTOLLFREE 16. GENERATOR'S CERTIFICATE: I hereby certify that the above -described materials are not hazardous wastes as defined by CFR Part 261 or any applicable state law, have been fully and accurately described, classified and packaged and are in proper condition for transportation according to applicable regulations. Printed Name Signature "On behalf oF" l ' /'d Month Day rear r n 17. Transporter 1 Acknowledgement of Receipt of Materials A Printed Name. Sig llrec Month Day Year 0 18. Transporter 2 Acknowledgement of Receipt of Materials r E Printed Name Signature g Month Day Year 19. Certificate of Final Treatment/Disposal I certify, on behalf of the above listed treatment facility, that to the best of my knowledge, the above -described waste was managed in compliance with all C applicable laws, regulations, permits and licenses on the dates listed above. 20. Facility wner or Operator: Certif 5fipn of re ipt of non -hazardous ma ri covered by this manifest. rioted e. Si natur D rear / hits-TRF TMFNT GTnRAr nlcpncA1 FArr TVrnnv nr.._ _' Yellow- 3 COPY Pink- FACILITY USE ONLY Gold- TRANSPORTER Ill COPY A NON -HAZARDOUS MANIFEST WASTE MANAGEMENT NON -HAZARDOUS MANIFEST 1. Generator's US EPA ID No. Manifest Doc No. 2. Page 1 of 3. Generator's Mailing Address: PQIMLtt.'o &iv+lroe)imtr'1tcj Ij G 9 5 Yo t It 5tr _ . t en r, GO'16 4. Generator's Phone 303-825-8117 Generator's Site Address judltterent than manmg): WELD COUNTY GOVERNMENT 1113 H STREET GREELEY, CO 80631 A. Manifest Number WMNA 10615531 B. State Generator's ID 5. STran, �P'orte`I Company Name in l Up it VCk 1✓l,j t�(_C s-1 6 re - Q t)4;tr1 FceJcC., GD 6. US EPA ID Number C. State Transporter's ID D. Transporter's Phone 7. Transporter 2 Company Nam 8. U5 EPA ID Number E. State Transporter's ID F. Transporter's Phone 9. Designated Facility Name and Site Address NORTH WELD LANDFILL 40000 WELD COUNTY RD 25 AULT CO 80610 10. US EPA ID Number G. State Facility ID H. State Facility Phone 970-545-5015 G 11. Description of Waste Materials 12. Canta_ners 13. Total QuanFty 14. unit WI/Vol Misc. Comments No. Type E N E R A a. NON REGULATED SOLID —EXCLUDED UST CONTAMINATED SOIL WM Proflle # 133126CO yar T 0 R b. WM Profile # IIIIIIIIIIIIIIIII] C WM Profile # ( — d. WM Profile # J. Additional Descriptions for Materials Listed Above ACCT#: N 10039 CUST NAME: PALMETTO ENVIRONMENTAL K. Disposal Location Cell i Level Grid 15. Special Handling Instructions and Additional Information Purchase Order It 14027 EMERGENCY CONTACT/ PHONE NO.: 1-8OO-424-93OO 24HR TOLL FREE 16. GENERATOR'S CERTIFICATE: I hereby certify that the above -described materials are not hazardous wastes as defined by CFR Part 261 or any applicable state law, have been fully and accurately described, classified and packaged and are in proper condition for transportation,c ordin to pplicable re . ns. Printed Name C1... to he ��if' Signature "On behalf of" - '� Month Day Tear r 17. Transporter 1 Acknowledgement of Receipt of Materials n S Print d Na Sin nth rear o 18. Transporter 2 Acknowledgement of Receipt of Materials Printed Name Si nature g Monih Day Year I 19. Certificate of Final Treatment/Disposal certify, on behalf of the above listed treatment facility, that to the best of my knowledge, the above -described waste was managed in compliance with all applicable laws, regulations, permits and licenses on the dates listed above. 20. Facility pwner or Operator: Certification of receipt of non -hazardous tp4terials co rr y this manifest. tinted a e % - Signatu / Mwnt� a, IL White- TR ATMF . CTnRAh 5t Pnc s, rant Tallow- OCNtKAi OR #1 COPY Pink- FACILITY USE ONLY Gold- TRANSPORTER #1 COPY / j _ ■Mnn WTT� NON -HAZARDOUS MANIFEST WASTE MANAGEMENT NON -HAZARDOUS MANIFEST 1. Generator's US EPA ID No. Manifest Doc No. 2. Page 1 of 3. Generator's Mailing Address: PQ Ir1 ettt0 Enviro1'� J Generator's Site Address lltdillerent than mailln`l: A. Manifest Number rnei to WELD COUNTY GOVERNMENT 10615556 Wg95 York 5lreet, 1113 H STREET WMNA B. State Generator's ID D enver, CO 5SO :9-16 GREELEY, CO 80631 4. Generator's Phone 303-825-8117 S. Transporter 1 Company Name TZ T ruck:h5 6. US EPA ID Number C. State Transporter's ID ! ` ( 9 3I 5 `1 et St D. Transporter's Phone G old t W 7toi-IT c() 7. Transporter 2 Company Name 8. US EPA ID Number E. State Transporter's ID F. Transporter's Phone 9. Designated Facility Name and Site Address 10. US EPA ID Number NORTH WELD LANDFILL G. State Facility ID 40000 WELD COUNTY RD 25 H. State Facility Phone 970 545 5015 AULT CO 80610 11. Description of Waste Materials 12. Containers 13. total 14. Unit No. Type G Quantity wLNol. t. Misc Comments E a. NON REGULATED SOLID — EXCLUDED LIST CONTAMINATED N SOIL E R WM Profile # 133126CO Ab T T 0 ( ( I R WM Profile # {fl I c f WM Profile # _______ d. ( WM Profile q J. Additional Descriptions for Materials Listed Above K. Disposal Location ACCT # : N 10039 CUST NAME: PALMETTO ENVIRONMENTAL Cell J I Level Grid 15. Special Handling Instructions and Additional Information Purchase Order# 14027 EMERGENCY CONTACT/ PHONE NO.: 1-800-424-9300 24HR TOLL FREE 16. GENERATOR'S CERTIFICATE: I hereby certify that the above -described materials are not hazardous wastes as defined by CFR Part 261 or any applicable state law, have been fully and accurately described, classified and packaged and are in proper condition for transportation according to applicable regula ' ns. Printed Name /t I Signature "On behalf of' Month Day Year hLr' B - rC �7 b L9 I t a 17. Transporter 1 Acknowledgement of Receipt of Materials A 'IDaV Printed N Signature c Month Year �j, __ 0 18. Transporter 2 Acknowledgement of Receipt of Materials 0. Printed Name Signature g Month Day Ycar ,]I19. Certificate of Final Treatment/Disposal I certify, on behalf of the above listed treatment facility, that to the best of my knowledge, the above -described waste was managed in compliance with all applicable laws, regulations, permits and licenses on the dates listed above. [ 20 Facility her or Operator: Certification of receipt of non-hazardous,materialecovered by this manifest. P nted Na Q t Signal re Whig- TRFATMFNT STrIROGF ntcorscerc nt try rnnv _ ..... -. _......-, ..�,�. , .-....,,...- ..r, q,ue- v[nn 1 Vn e. COPY Yellow- GENERATOR #1 COPY Pink- FACILITY USE ONLY Gold- TRANSPORTER #1 COPY 21 ��4ni U-r\r_ NUASTE MANAOEMEttT " NON -HAZARDOUS MANIFEST NON -HAZARDOUS MANIFEST 1. Generator's US EPA ID No. Manifest Doc No. 2. Page 1 of 3. Generator's Mailing Address: Pal rte-tLo 6Od;forsm uv1a Generator's Site Address tndiffernnt than mailing): WELD A. Manifest Number COUNTY GOVERNMENT 10615533 ICY, Stre2.,t 1113 H STREET WMNA B. State Generator's ID DL'ti11tpj'1 CO r�dal GREELEY, CO 80631 4. Generator's Phone 303-825-8117 S. Transporter 1 Company Name Cof _e_o n1 6. US EPA ID Number C. State Transporter's ID a -Ajv Am 5Ce7 Dr. D. Transporter's Phone O 4 7. Transporter 2 Company Name B. US EPA ID Number E. State Transporter's ID F. Transporter's Phone 9. Designated Facility Name and Site Address 10. US EPA ID Number NORTH WELD LANDFILL G. State Facility ID 40000 WELD COUNTY RD 25 H. State Facility Phone 970-545-5015 AULT CO 80610 11. Description of Waste Materials IL containers 13. Total 14. umt No. Type G Quantity Wt/Vnl. 1. Misc. Comments a. NON REGULATED SOLID — EXCLUDED UST CONTAMINATED N SOIL E I R WM Profile it 133126CO A b T R WM Profile # WM Profle # d. WM Profile it I 1. Additional Descriptions for Materials Listed Above K. Disposal Location ACCT #: N 10039 CUST NAME: PALMETTO ENVIRONMENTAL Cell Level Grid 15. Special Handling Instructions and Additional Information Purchase Order # 14027 EMERGENCY CONTACT/PHONENO.: 1-800-424-9300 24HRTOLL FREE 16. GENERATOR'S CERTIFICATE: I hereby certify that the above -described materials are not hazardous wastes as defined by CFR Part 261 or any applicable state law, have been fully and accurately described, classified and packaged and are in proper condition for transportation a cording to applicable regulations. Printed Name Signature "On behalf of i Month Day Year �,�1Ct � '� E`C V'. SS r R 17. Transporter 1 Acknowledgement of Receipt of Materials A Printed Name ��_� Signature Month Day Ycar _� IQ r� C7 18. Transporter 2 Acknow edgement of Receipt of Materials Printed Name Si nature g Month Day Year 19. Certificate of Final Treatment/Disposal A I certify, on behalf of the above listed treatment facility, that to the best of my knowledge, the above -described waste was managed in compliance with all applicable laws, regulations, permits and licenses on the dates listed above. J 20., Facility Ow er or Operator: Certification of receipt of non-hazardou materl S covered by this manifest. P'rtfedN � .� Sign Uf '� bbnth Day Year ti ite- TREATMENT S nRACF niconc si care IN rnov Yellow- latNtKArOR#1 COPY Pink- FACILITY USE ONLY Gold- TRANSPORTER #1 COPY ■Mr\lam VW NON -HAZARDOUS MANIFEST NON -HAZARDOUS MANIFEST 1. Generator's US EPA ID No. Manifest Doc No. 2. Page 1 of 3. Generator's Mailing Address: Generator's Site Address (It dinerent than mailing): A. Manifest Number PQlmgtto £n✓;rOnrnr;'' l WELD COUNTY GOVERNMENT 10615534 4qq t) yor K Str&b 1113 H STREET WMNA B. State Generator's ID Diver, CO �i�� iF� GREELEY, CO 80631 4. Generator's Phone 303-825-8117 5. Transporter 1 Company Name try CVp'TrVCIc vi ILC. 6. US EPA ID Number C. State Transporter's ID , N- Ek0W D. Transporter's Phone r r; 7. Transporter 2 Company Name 8. US EPA ID Number E. State Transporter's ID 9, Designated Facility Name and Site Address 10. US EPA ID Number F. Transporter's Phone NORTH WELD LANDFILL G. State Facility ID 40000 WELD COUNTY RD 25 H. State Facility Phone 970-545-5015 AULT CO 80610 11. Description of Waste Materials 12. conta,ners 13. Tara) 14. Unn No.I Type G QuantityW,./Vol, I. Misr Comments E a. NON REGULATED SOLID — EXCLUDED LIST CONTAMINATED N SOIL 1 Yo r J5 E 1 R WM Profile # 133126CO Mb T I0 R WM Profile If � + C. WM Profile It d. WM Profile # J. Additional Descriptions for Materials Listed Above K. Disposal Location ACCT # : N 10039 CUST NAME: PALMETTO ENVIRONMENTAL Cell I Level Grid 15. Special Handling Instructions and Additional Information Purchase Order It 14027 EMERGENCY CONTACT / PHONE NO.: 1-800-424-9300 24HR TOLL FREE 16. GENERATOR'S CERTIFICATE: I hereby certify that the above -described materials are not hazardous wastes as defined by CFR Part 261 or any applicable state law, have been fully and accurately described, classified and packaged and are in proper condition for transportation according to applicable reg ions. Printed Name �r) Signature "On behalf of" Month DaY VCar (-, � h/ (� R i r ' q F-� J CA � 17. Tr nsporter 1 Acknowledgement of Receipt of Materials N Prin�Signaturg _ ��--� Month DaY Ycar tL 0 18. Transporter 2 Acknowledgement of Receipt of Materials Printed Name ertificate of Final Treatment/Disposal e I certify, on behalf otjb fisted treatment facility, that to the best of my knowledge, the above -described waste was managed in compliance with all applicable laws, r i,lations, per its and licenses on the dates listed above. 20. Facility 9u�iner or Operato Ce ification of receipt of non -hazardous materials covered by this manifest. Print am Signature /� - Mon DaV Yea White- T -ATMFNT STr1R.GF nicnrscar rent ITV rnov r, Teu0W-OtNtHAIUR#1COPY Pink- FACILITY USE ONLY Gold- TRANSPORTER #1 COPY /, ■ m /-1 F_t MANAGEMENT WASTE , NON -HAZARDOUS MANIFEST NON -HAZARDOUS MANIFEST 1. Generator's US EPA ID No. Manifest Doc No. 2. Page 1 of 3. Generator's Mailing Address: Pa t rnj O Generator's Site Address (it different than matngl: WELD COUNTY A. Manifest Number GOVERNMENT 10615529 qTy99 J VO(k `J�.f e,t' — 1113 H STREET WMNA V evi r Cv 16O;,I �j / GREELEY, CO 80631 B. State Generator's ID 4. Generator's Phone 303-825-8117 5. Transporter 1 Company Name TinCUp IrUGlC,viOi�,LC JJI 6. US EPA ID Number C. StateTransporter'sio 376' C.Urt,�' Q(1 ) 4 � D. Transporter's er's Phone r ri 7. Transporter 2 Company Name 8. US EPA ID Number E. State Transporter's ID 9. Designated Facility Name and Site Address 10. US EPA ID Number F. Transporter's Phone NORTH WELD LANDFILL G. State Facility ID 40000 WELD COUNTY RD 25 H. State Facility Phone 970-545-5015 AULT CO 80610 { 11. Description of Waste Materials 12. Containers B. Total 14. Unit No• TYM G E a. NON REGULATED SOLID — EXCLUDED UST CONTAMINATED Quantity wt/vo1 I. Mist Comments J N SOIL E Y R WM Profile # 133126CO b T r 0 R WM Profile # WM Profile # d. WM Profile # J. Additional Descriptions for Materials Listed Above K. Disposal Location ACCT #: : N 10039 CUST NAME: PALMETTO ENVIRONMENTAL Cell Level Grid 15. Special Handling Instructions and Additional Information Purchase Order # 14027 EMERGENCY CONTACT / PHONE NO.: 1-800-424-9300 24H R TOLL FREE 16. GENERATOR'S CERTIFICATE: I hereby certify that the above -described materials are not hazardous wastes as defined by CFR Part 261 or any accurately described, classified and packaged and in applicable state law, have been fully and are proper condition for transportation according to pplicable regulations. Printed Name Signature "On behalf of" 1/t Month paY Year /J - W 17. Transporter 1 Acknowledgement of Receipt of Materials n 1r i ed me Signatu Month Day Year 0 18. Transporter 2 A knowledgement Receipt of Materials r Printed Name Signature r Month pay Year F 19. Certificate of Final Treatment/Disposal A c I certify, on behalf of the above listed treatment facility, that to the best of my knowledge, the above -described applicable laws, regulations, permits and licenses on the dates listed wart s managed in compliance with all above. 20. Facility Owner or Operator: Certification of receipt o9non-hazardetus ma riais covered by this manifest. e rinte Name ` Mun Day rear White- R ATMENT, STORAGE, DISPOSAL FACILITY COPY hm- r:Gtacanmo r enuw- uuvt KA i U K aPt:UPY Pink- FACILITY USE ONLY Gold- TRANSPORTER R1 COPY S 0's WT6MA�--A MLA NON -HAZARDOUS MANIFEST NON -HAZARDOUS MANIFEST 1. Generator's US EPA ID No. Manifest Doc No. 2. Page 1 of 3. Generator's Mailing Address: Pct I Generator's Site Address (it different thanmainng): A. Manifest Number ('1 tto Cmer<1ta WELD COUNTY GOVERNMENT 10615540 114 Q Yo( K 5tr& . 1113 H STREET WMNA 8. State Generator's ID Denvef, Co gO).16 GREELEY, CO 80631 4. Generator's Phone 303-825-8117 5. Transporter 1 Company Name 6. US EPA ID Number TZ'Trve, K' n9 C. State Transporter's ID f Yv► D. Transporter's Phone n 7. Transporter 2 Company Name 8. US EPA ID Number E. State Transporter's ID 9. Designated Facility Name and Site Address 10. US EPA ID Number F. Transporter's Phone NORTH WELD LANDFILL G. State Facility ID 40000 WELD COUNTY RD 25 H. State Facility Phone 970-545-5015 AULT CO 80610 11. Description of Waste Materials 12. cantaner3 13. Total 14. ur c (Vo. Type G Quantity wt.Nd. I. Mist Comments E a. NON REGULATED SOLID — EXCLUDED UST CONTAMINATED N SOIL 1 Q} yC4 rc�5 E E ( % R WM Profile # 133126CO A b. T O I I I R WM Profile # WM Profile # d. I I WM Profile # J. Additional Descriptions for Materials Listed Above K. Disposal Location ACCT #: N 10039 CUST NAME: PALMETTO ENVIRONMENTAL Cell Level Grid 15. Special Handling Instructions and Additional Information Purchase Order if 14027 EMERGENCY CONTACT/P PHONE NO.: 1-800-424-9300 24HR TOLL FREE 16. GENERATOR'S CERTIFICATE: I hereby certify that the above -described materials are not hazardous wastes as defined by CFR Part 261 or any applicable state law, have been fully and accurately described, classified and packaged and re in proper condition for transportation ac rding to applicabi re ulati s. Printed NameSignature nature "On behalf of Month Day Yea r;sto her '�;f ,,s l�iL r R 17. Transporter 1 Acknowledgement of Receipt of Materials Printed Name ) rte• Signature / 77 Montn Day Ycar S w h ^ 1 J , 18. Transporter 2 cknowledgement of Receipt of Materials Printed Name t Si naure g E Month Day Year 19. Certificate of Final Treatment/Disposal I certify, on behalf of the above listed treatment facility, that to the best of my knowledge, the above -described waste was managed in compliance with all applicable laws, regulations, permits and licenses on the dates listed above. 20. Facility Owner or Operator: Certification of receipt of non -hazardous materials covered by this mpi est. Y Pri to ame Sin u ` g� •� l ^'� ar White- TREATMENT. STORAGE. DIS nSAt FAnt ]Tv rnnv m.. �. �� r Yellow- c,trvtKAFOR #1 COPY Pink- FACILITY USE ONLY Gold- TRANSPORTER #1 COPY ■Mn>n W H, dJ NON -HAZARDOUS MANIFEST NON -HAZARDOUS MANIFEST 1. Generator's US EPA ID No. Manifest Doc No. 2. Page 1 of 3. Generator's Mailing Address: PaIrnetro 6rVrrocsmeiht1 Generator's Site Address pt different than malItngi: WELD COUNTY GOVERNMENT A. Manifest Number 10615532 I °15 YOf K 3tret✓4 1113 H STREET WMNA B. State Generator's ID �✓1J,.-1'3 GO 0:.►o GREELEY, CO 80631 4. Generator's Phone 303-825-8117 5. Transporter 1 Company Name Car rearp) Tr Uc. k 5rr� 6. US EPA ID Number C. State Transporter's ID Mrf3t D.Transporter'sPhone 7. Transporter 2 Company Name 8. US EPA ID Number E. State Transporter's ID 9. Designated Facility Name and Site Address 10. US EPA ID Number F. Transporter's Phone NORTH WELD LANDFILL G. State Facility ID 40000 WELD COUNTY RD 25 H. State Facility Phone 97O -545-5O15 AULT CO 80610 11. Description of Waste Materials 12. Containers 13. Total 14. Jolt Na. T" G Quantity Wt/Val. L biis[. Comments E a. NON REGULATED SOLID — EXCLUDED UST CONTAMINATED N SOIL E R WM Profile # 133126CO A b T O R WM Profile # i WM Profile d. WM Profile It I _________________ J. Additional Descriptions for Materials Listed Above ________ K. Disposal Location ACCT if: N 10039 CUST NAME: PALMETTO ENVIRONMENTAL Lf!!L jLevel Grid 15. Special Handling Instructions and Additional Information Purchase Order # 14027 EMERGENCY CONTACT / PHONE NO.: 1-800-424-9300 24HR TOLL FREE 16. GENERATOR'S CERTIFICATE: I hereby certify that the above -described materials are not hazardous wastes as defined by CFR Part 261 or any applicable state law, have been fully and accurately described, classified and packaged and proper condition for transportation,ac ording to applicable regulat• s. PrintedName f ( Signature "On behalf of jt c. t-' t'� �7 _ Month Day Year 4W!! T R 17. Transporter 1 Acknowledgement of Receipt of Materials A Printed Name Signature a 5 R J i L/ 1 �Gf.Y t "_ Mornh Day Year 18. Transporter 2 Acknowledgement of Receipt of Materials . Printed Name I Signature Month Day Year 19. Certificate of Final Treatment/Disposal I certify, on behalf of the above listed treatment facility, that to the best of my knowledge, the above -described waste was managed in compliance with all applicable laws, regulations, permits and licenses on the dates listed above. P� 20. Facility Owner or Operator: Certification of receipt of non-hazardg mate overed by this manifes£ rioted a Sin ure / White- TR ATMENT. ST AGE- SPOSAI FAIN ITV rncv tr,e_ �t A ro AT , Yellow- btrvtRAIUN #1 COPY Pink FACILITY USE ONLY Gold- TRANSPORTER 111 COPY vin,, NON -HAZARDOUS WASTE MANAGEMENT MANIFEST NON -HAZARDOUS MANIFEST 1. Generator's US EPA ID No. Manifest Doc No. 2. Page 1 of 3. Generator's Mailing Address: Generator's Site Address (v different than malunal: Palmetto A4 A. Manifest Number WELD COUNTY GOVERNMENT ulE45 Yof K 5't&- WMNA 10615539 1113 H STREET Co ItiO -)-J % GREELEY, CO 80631 B. State Generator's ID 4. Generator's Phone 303-825-8117 5. Transporter 1 Company Name 6. US EPA ID Number i�r< •� j1 Jaw �;. i, • H " J• - I C. State Transporter's ID D.Transporter'sPhone I I 7. Transporter 2 Company Name 8. US EPA ID Number E. State Transporter's ID 9. Designated Facility Name and Site Address 10. US EPA ID Number F. Transporter's Phone NORTH WELD LANDFILL G. State Facility ID •H. 40000 WELD COUNTY RD 25 S tate Facility Phone 970-545-5015 AULT CO 80610 11. Description of Waste Materials 12. contarne, 13. Total 14. Unit No. Type 1. Misc. Cnmmenl5 G E a. NON REGULATED SOLID —EXCLUDED UST CONTAMINATED Quantity WI flint N E SOIL R WM Profile # 133126CO A b O O I I R WM Profile 1Y WM Profile p WM Profile it J. Additional Descriptions for Materials Usted Above K. Disposal location ACCT #: N 10039 CUST NAME: PALMETTO ENVIRONMENTAL Cell I Level Grid 15. Special Handling Instructions and Additional Information Purchase Order It 14027 EMERGENCY CONTACT / PHONE NO.: 1-800-424-9300 24HR TOLL FREE 16. GENERATOR'S CERTIFICATE: I hereby certify that the above -described materials are not hazardous wastes as defined by CFR Part 261 or any applicable state law, have been fully and accurately described, classified and packaged and are in for proper condition transportation acc rding to applicable Signature "On behalf of" Printed NameC�is{� her 'Q r regulations. Month Day Year 1 �irc J. T a 17. Transporter 1 Acknowledgement of Receipt of Materials A Prince ,Name _ �— / Si nature Ma,tn Day rear 0 a 18. Transporter 2 Acknowledgement of Receipt of Materials % t Printed Name Signature e Month Dav Year 19. Certificate of Final Treatment/Disposal A I certify, on behalf of the above listed treatment facility, that to the best of my knowwdge, the above -described waste was managed in compliance with applicable laws, regulations, permits and licenses on the dates listed above. all 20. Facility Owner or Operator: Certification of receipt of non-hazardou mate als covered by this manifest. inted e �J/ 1f Siena re l,i r, - / , ,it:� Atan �t ear ►/ hite- TREA MENT, STORAGE, DISPOSAL FACILITY Cnpv ai ,6_ ( FNCn AT 1n Tellow- btNtRA I OR Ill COPY 1 Pink- FACILITY USE ONLY Gold- TRANSPORTER lit COPY 4.J • WINX NON -HAZARDOUS etrANAgBM6N7' MANIFEST 7 _ R onto M —t. I )e MA it, ii.. NON -HAZARDOUS MANIFEST _ .._. •r aIuIiat &uI no, Z. rage , of A. Manifest Number 9. Generator's Mailing Address: Generator's Site Address (If dtnar.Rt than maUIng r ytvlrnt+.Y1.��et l WELD COUNTY GOVERNMENT q.5 /o ^c7�.i'�.� WMNA 10615542 4i 1113 H STREET GREELEY, CO 80631 B. State Generator's ID 4. Generator's Phone 303-825-8117 55rr Transporter 1 Company Name 6. US EPA ID Number }"W. ,\\ !I I: &' C. State Transporter s iD '„' 7. Transporter 2 company Name 8. US EPA ID Number D.Transporter'sPhone 1 I.. I t" r, a I; t , t l l;•I I ;: " E. State Transporter's ID I• 9. Designated Facility Name and Site Address 10. US EPA ID Number F. Trans orter's Phone ,,. ; L :3 NORTH WELD LANDFILL : ::: ;:, ;,•., 40000 WELD COUNTY RD 25 I''" ! ! ' • I" •.•I G. State Facility ID r • • •t; AULT CO 80510 H. State Facility Phone 970-545-5015 �;+!"., ,•F • !tI Description of Waste Materials 12. ont.4lma Ttl i4. G +'�• TYp• E a. NON REGULATED SOLiD—EXCLUDED UST CONTAMINATED Quantity wt./vol. P. mbcC comments N SOIL R WM Profle # 133126CO 2 Q 1, i!:"• ;r 7:; R WM Profile ri C. �I}, •+' I: 1. I 7! I hFt"` ~i.: .. it ; . +f' WM Profile p ; :i ,. .6)' :i'pri ,u . ;ca:. :: WM Prof le# '.ii: L.: ri" ar;t irr. J. Additional Descriptions for Materials Listed Above K. Disposal Location ACCT #: N 10039 CUST NAME: PALMETTO ENVIRONMENTAL Cell F Level Grid 15. Special Handling Instructions and Additional information 'n,:c I I•'. .iila; I,iiL. i IiI, Purchase Order # 14027 EMERGENCY CONTACT / PHONE N0.: 1800-424•-9300 24HR TOLL FREE 16.. GENERATORISCER7mFICATE; I hereby certify that the above -described materials are not hazardous wastes as defined by CFR Part 261 or any applicable state law, have been fully accuratalydescrlbed, clessiied and packs ed and are In proper condition for Iran ortatlon accordin to a Printed and Iicabie regulations. Name Signature "On behalf of. „/ Mono T R 17. Transporter 1 Acknowledgement of Receipt of Materials e Fri ame Signatur R nth Year o 1B. Trans rter2Acknowled Po Bement of Receipt of MateHais �" Printed Name Signature e It Month n tY Year 19. Certificate of Final Treatment/Disposal n I certify, on behalf of the above listed treatment facility, that to the best of my knowledge, the above -described waste was managed in compliance with all applicable laws, regulations, permits and licenses an the dates listed above, 20. Facility Owner or Operator: Certification of receipt of non -hazardous aterl covered by this menu f I. r Print Name Signs Day hate -T EATM NT STORA$,Is OSAL FACILITY COPY Btu ..GFNFRGT o tf7 rnov f / 7Year v V -- - - --• • rcnwrr:IViluItattOPy Pink- FACILITY USE ONLY Gold- TRANSPOR`I•ER #1 COPY 26Nr6�ug -Mr\n-\ NON -HAZARDOUS MANIFEST NON -HAZARDOUS MANIFEST 1. Generator's US EPA ID No. Manifest Doc No. 2. Page 1 of 3. Generator's Mailing Address: N1r+tt,Gto & iroomeii ! 4qq 5 Yor K 5tree;b Dex sex, CO '6O i e 4. Generator's Phone 303-825-8117 Generator's Site Address iii ddiferent than mailing): WELD COUNTY GOVERNMENT 1113 H STREET GREELEY, CO 80631 A. Manifest Number WMNA 10615530 B. State Generator's ID 5. Transporter — 1 Company Name Ti Irvct.tg') 1 L19 3 S�+ r 'w t SLYt' i LJnt yytortt 6. US EPA ID Number C. State Transporter's ID D. Transporter's Phone 7. Transporter 2 Company Name 8. US EPA ID Number E. State Transporter's ID F. Transporter's Phone 9. Designated Facility Name and Site Address NORTH WELD LANDFILL 40000 WELD COUNTY RD 25 AU LT CO 80610 10. US EPA ID Number G. State Facility ID H. State Facility Phone 970-545-5015 G 11. Description of Waste Materials u. containers 13. Total Quantify 14. unit wt.Nd. I. Misc. Comments Alo. type E N E R a. NON REGULATED SOLID — EXCLUDED LIST CONTAMINATED SOIL WM Profile # 133126CO 1% J A I O R b WM Profile a I ! I C. WM Profile IS d. WM Profile It 1. Additional Descriptions for Materials Listed Above ACCT # : N 10039 CUST NAME: PALMETTO ENVIRONMENTAL K. Disposal Location Cell Level Grid 15. Special Handling Instructions and Additional Information Purchase Order # 14027 EMERGENCY CONTACT / PHONE NO.: 1-800-424-9300 24HR TOLL FREE 16. GENERATOR'S CERTIFICATE: I hereby certify that the above -described materials are not hazardous wastes as defined by CFR Part 261 or any applicable state law, have been fully and accurately described, classified and packaged and are in proper condition for transportation according to applicable dons. Printed Name CHrts lr Signature "On behalf r&0 '� Month Day Ytar r n 17. Transporter 1 Ackn wledgement of Receipt of Materials A Printed Na /1 1 Signature nth Da Year 18. Transporter 2 Acknowledgement of Receipt of Materials Printed Name r Signature Month Day Year 19. Certificate of Final Treatment/Disposal I certify, on behalf of the above listed treatment facility, that to the best of my knowledge, the above -described waste was managed in compliance with all applicable laws, regulations, permits and licenses on the dates listed above. 20. Fa 'lily O, ner or Operator: Certification of receipt of non -hazardous material '.51do,ered by this manifest. nL G l L1✓ to/t.*n_T tATAArk,t crnnn/_c n Signa Gfe .✓ /1 M t Day Year , �,.�.. nz rr Yellow- (itivtRAIUR31COPY Pink- FACILITY USE ONLY Gold- TRANSPORTER #1 COPY U = r_\/ -t VWv =. NON -HAZARDOUS MANIFEST NON -HAZARDOUS MANIFEST 1. Generator's US EPA ID No. Manifest Doc No. 2. Page 1 of 3. Generator's Mailing Address. ' Pa1Imetje, F r6n Generator's Site Address l different than n,aningl: WELD COUNTY A. Manifest Number GOVERNMENT 10615541 t-jgq`J y0t K Str & 1113 H STREET WMNA B. State Generator's ID Deer, Co sb`)J, GREELEY, CO 8O631 4. Generator's Phone 303-825-8117 5. Transporter 1 Company Name CfO! t THUG k N9 6. US EPA ID Number C. State Transporter's ID �O A�r LoIa D. Transporter's Phone 7. Transporter 2 Company Name 8. US EPA ID Number E. State Transporter's ID 9. Designated Facility Name and Site Address 10. US•EPA ID Number F. Transporter's Phone NORTH WELD LANDFILL G. State Facility ID 40000 WELD COUNTY RD 25 H. State Facility Phone 970-545-5015 AULT CO 80610 11. Description of Waste Materials 12- Containers la. Total 1.5. unit No. Type G Quantih Wt /Vol. I. M sc Comments E a. NON REGULATED SOLID — EXCLUDED UST CONTAMINATED N SOIL YQ r�S E R A WM Profile 8 133126CO b. T 0 R WM Profile 8 C. WM Profile 8 d. � WM Profile 8 t J. Additional Descriptions for Materials Listed Above K. Disposal Location ACCT U: N 10039 CUST NAME: PALMETTO ENVIRONMENTAL Cell I Level Grid 15. Special Handling Instructions and Additional Information Purchase Order 8 14027 EMERGENCY CONTACT / PHONE NO.: 1-800-424-9300 24HR TOLL FREE 16. GENERATOR'S CERTIFICATE: I hereby certify that the above -described materials are not hazardous wastes as defined by CFR Part 261 or any applicable state law, have been fully and accurately described, classified and packaged and are in proper condition for transportation according to applicable regulations. Printed Name f �� r1S Signature "On behalf of/j/�_ Monti, Day Year p t� 17. Transporter 1 Acknowledgement of Receipt of Materials s Printed Name "] - / n, f�l'�E )`I ��i, \ LYE Signature / Month Day Year 0 18. Transporter 2 Acknowledgement of Receipt of Materials ° Printed Name Signature Llonth Day Ycar R 19. Certificate of Final Treatment/Disposal a I certify, on behalf of the above listed treatment facility, that to the best of my knowledge, the above -described waste was managed in compliance with all applicable laws, regulations, permits and licenses on the dates listed above. 20. Facility Owner or Operator: Certification of receipt of non -hazardous materials co red by this manifest. �/' Pri�sted ame r$ 1 Si nature g atom Oa —x�ar White- TREATMENT. STORArF nicpntai Faris rry rnov Pink- FACILITY USE ONLY Gold- TRANSPORTER fl1 COPY cuu vr- USivova tUn &1 l.UCY s / �?&' ¶7Z 1 M a___\ WIC NON -HAZARDOUS MANIFEST NON -HAZARDOUS MANIFEST 1. Generator's US EPA ID No. Manifest Doc No. 2. Page 1 of 3. Generator's Mailing Address: Palm&tLo Cy vtrpn rrenta 1 ) S YOr K StL Dpys'.tr, CO $Op21(-, 4. Generator's Phone 303-825-8117 Generator's Site Address it different than mailing): I WELD COUNTY GOVERNMENT J 1113 H STREET GREELEY, CO 80631 A. Manifest Number WMNA 10615543 B. State Generator's ID 5. Transporter 1 Company Name Tin Cvp irvCtct"l 376 lnkt #14W F rjrtc..K Gp 6. US EPA ID Number C. State Transporter's ID D. Transporter's Phone 7. Transporter 2 Company Name 8. US EPA ID Number E. State Transporter's ID F. Transporter's Phone 9. Designated Facility Name and Site Address NORTH WELD LANDFILL 40000 WELD COUNTY RD 25 AULT CO 80610 10. US EPA ID Number G. State Facility ID H. State Facility Phone 970-545-5015 G 11. Description of Waste Materials 12. Containers 13. Total Quantity 14. Unit Wt./Vol. t. Misc. Comments No. Type E N E R a. NON REGULATED SOLID — EXCLUDED LIST CONTAMINATED SOIL WM Profile tl 133126CO 13 ygI'd T 0 R b - WM Profile ff I ( 1 I C. WM Profile ff I I I I d. WM Profile If J. Additional Descriptions for Materials Listed Above � ACCT #: N 10039 CUST NAME: PALMETTO ENVIRONMENTAL K. Disposal Location Cell I level Grid 15. Special Handling Instructions and Additional Information Purchase Order it 14027 EMERGENCY CONTACT/ PHONE NO.: 1-800-424-9300 24HR TOLL FREE 16. GENERATOR'S CERTIFICATE: I hereby certify that the above -described materials are not hazardous wastes as defined by CFR Part 261 or any applicable state law, have been fully and accurately described, classified and packaged and are in proper condition for transportation according to applicable regulations. Printed Name sr he _r Signature "On behalf of" Month Day Year 1 R 17. Transporter 1 Acknowledgement of Receipt of Materials N Prt led Na a _ Signature Month Day year 18. Transporter 2 Acknowledgement of Receipt of Materials T C R Printed Name Signature nature Month Day Year A 19. Certificate of Final Treatment/Disposal I certify, on behalf of the above listed treatment facility, that to the best of my knowledge, the above -described waste was managed in compliance with all applicable laws, regulations, permits and licenses on the dates listed above. /� a 20. Facility Owner or Operator: Certification of receipt of non -hazardous material overed by this manifest. / /rJfled N'�(J�j e�� { 1• Whitr-TRFATRIFRIT cTneAr c ntconCA cnr-uiry nnnv Signatur --�' / "..,,. n „� ,_,r, Yenow- UtNLRAIOR tf1 COPY Pink- FACILITY USE ONLY Gold- TRANSPORTER it1 COPY 7oL(' 'T-71 NON -HAZARDOUS MANIFEST 1, Generator's US EPA ID No. Manifest Doc No. NON -HAZARDOUS MANIFEST 2, Page 1 of 3 Generator's Mailing Address: 'dIr4d''�+b Env3reT�ct� Generator's Site Address (tfdaferente,.ninanrnsk WELD A. Manifest Number COUNTY GOVERNMENT 10615546 448street 1113 H STREET ANA B. State Generator's iP +rv11L"Y �3'0,�41�j GREELEY, CO 80631 4, Generator's Phone 303-825-8117 5. Transporter I Company Name Ty-, CUP TrdGA• n B. US EPA lb Number '::: .': . s• t., H C. State Transporter's ID • .. ;.: , .i l :;, , ! 4 i� 8, US EPA I0 Number D, Transporter's Phone s• „.a: • •" '. 7, Transporter 2 Cem y Nettle r,i:.j•• ,., ;,;,, ;ir '.li. E. StateTransporterslo F. Trans orter's Phone ! ;,; , p,.; 9, Designated Facility Name and Site Address 10. US EPA ID Number ; 1:;; :q;. ° NORTH WELD LANDFILL .i f+ :4; ...'t' ' ; G, State Facility ID ;1; ,:•;, ;,:• 40000 WELD COUNTY RD 25 , q.i,,. .,. H. State Facility Phone 970-545.5015 AULT CO 80510 �., ,•lei!:.' rL+. (1!l :;, 'f !f'•y.. i___ ___ '.: t;r4f rl::� 'I 4• 'ii:'r• lY 11, Description of Waste Materials 12. Containers 13. Total 34. Unit G Na type 4uantay wt.Nol. I. itex, Canemnts E a, NON REGULATED SOLID- EXCLUDED UST CONTAMINATED N SOIL ;., LL.( r. • i E .. R WM Profiled 133126CO Tb. ..., R WM Profile N ?I 1' i r i ;r ' , • Fr .., WM Profile ® trr•. +,r :a `i; .'i. t," " E,+ d. .. , WMProflleq .;:,. .•,,,.I,;. !?' tN`: ;:�H'.. :jts!',i : .;.;: , f J. Additional Descriptions for Materials Listed Above K. Disposal Location ACCT# : N 10039 CUST NAME: PALMETTO ENVIRONMENTAL Cell Level Gdd 15, Special Handling Instructions and Additional Information Purchase Order# 14027 EMERGENCY CONTACT/PHONE NO.: 1-800.424-9300 24HR TOLL FREE 16. GENERATOR'S CERTIFICATE: I hereby certify that the above -described materials are not hazardous wastes as defined by CPR Part 261 or any applicable state law, have been fully and accurate described, classified and packaged and are in ro er condition for transportation aotbrdIng to a Ilcab(e re ulatlons, Printed Name71 t r ,' Signature "On behalf of" Marth o.Y Year. 5g , $ '1 r 17. Transporter 1 Acknowledgement of Receipt of Materials B Print N s u nn th V Year 0 18. Transporter 2 Aclmowledgement Receipt of Materials Printed Name Signature Month Day Ymr 19. Certificate of FinalTreatment/Disposal a I certify, on be aWiN't a above listed treatment facility, that to the best of my knowledge, the above -described waste was managed in compliance with applicable 1 s, regula ions, permits and licenses on the dates listed above, all L 20. Feel Awn Operat ; Certification of receipt of non -hazardous materials c dbythis manifest. v Pri d am ]s! ignature Month ea Va.r W e -TREATMENT_ ORAGE_ olcPr1gAI FArnrrvrrwv iii-------aCn aTnn --•---- .c.wwr-ucrvGI Utt rR GUPT Pink- FACILITY USE ONLY Gold- TRANSPORTER #1 COPY 9 WASTE MANAGEMENT NON -HAZARDOUS MANIFEST It NON -HAZARDOUS MANIFEST i 1. Generator's US EPA ID No. Manifest Doc No. 2. Page 1 of 3. Generator's Mailing Address: Palm&titO £n0rr)Md- ctA' Generator's Site Address (if different than maarngl: WELD COUNTY A. Manifest Number GOVERNMENT WMNA 10615544 i-1g95 yo(K 5tr�t 1113 H STREET B. State Generator's ID Dev ve , CO `6016 GREELEY, CO 8O631 4. Generator's Phone 303-825-8117 5. Transporter 1 Company Name Ti ) r L' � jnw 6. US EPA ID Number '.q31 5k ' ercjmc�S(�+ Lo C- State Transporter's ID D.Transporter'sPhone ► mo, fO 7. Transporter 2 Company Name 8. US EPA ID Number E. State Transporter's ID 9. Designated Facility Name and Site Address 10. US EPA ID Number F. Transporter's Phone NORTH WELD LANDFILL G. State Facility ID 40000 WELD COUNTY RD 25 H. State Facility Phone 970-545-5015 AULT CO 80610 11. Description of Waste Materials U. c0ntm^Ms 13. Total 14. unit No. Type G _trmtity wt.ryoi. I. Mist. Comments E a. NON REGULATED SOLID —EXCLUDED UST CONTAMINATED I N SOIL E E R WM Profile fI 133126CO Mb T 0 I. R WM Profile # ___ c. I ( I WM Profile IS d. WM Profile If J. Additional Descriptions for Materials Listed Above K. Disposal Location ACCT # : N 10039 CUST NAME: PALMETTO ENVIRONMENTAL Cell I Level Grid 15. Special Handling Instructions and Additional Information Purchase Order IS 14027 EMERGENCY CONTACT/ PHONE NO.: 1-800-424-9300 24HR TOLL FREE 16. GENERATOR'S CERTIFICATE: I hereby certify that the above -described materials are not hazardous wastes as defined by CFR Part 261 or any applicable state law, have been fully and accurately described, classified and packaged and a e in proper condition for transportation according to applicable re lations. Printed Name/1 � Signature "On behalf of atontn oay rear T A 17. Transporter 1 Ack owledgement of Receipt of Materials H Printed N Signal x i Month DaY Year 0 18. Transporter 2 Acknowi dgement of Receipt of Materials " Printed Name J Signature a t Month Day Year 19. Certificatoe Fi(tal Treatment/Disposal a I certify, on. ehalf of the above listed treatment facility, that to the best of my knowledge, the above -described waste was managed in compliance with all applicable laws, regulations, permits and licenses on the dates listed above. 20. F'1 'lily -OW or Operator: Certif'c"ation of receipt of non -hazardous materials -covered by this manifest. tinted N e / ., Signature !T � evlonth 0dY Year White- TREATMENT STORAGE DISPOSAL FACILITY COPY B GENE ue- RA I — ttZ COPY Yellow- GENERATOR i COPY Pink- FACILITY USE ONLY Gold- TRANSPORTER 91 COPY WV -n NON -HAZARDOUS WASTE MANAGEMENT MANIFEST NON -HAZARDOUS MANIFEST 1. Generator's US EPA ID No, Manifest Doc No, 2. Page 1 of 3. Generator's Mailing Address: Palme,tto Generator's Site Address (Ifdiferentthan mailing): A. Manifest Number &i v;ior'enl.aI WELD COUNTY GOVERNMENT 10615545 4qq, ya(St 1113 H STREET WMNA B. State Generator's ID �y' De C �DOL) i C� �J GREELEY, CO 80631 4. Generator's Phone 303-825-8117 S. Transporter I Company Name Cwireon Tevrr;vti(� 6. US EPA ID Number C. State Transporter's ID a3` 4l a-) D. Transporter's Phone 7. Transporter 2Company Name 8. US EPA ID Number E. State Transporter's ID 9. Designated Facility Name and Site Address io. US EPA ID Number F. Transporter's Phone NORTH WELD LANDFILL G. State Facility ID 40000 WELD COUNTY RD 25 H. State Facility Phone 970-545-5015 AULT CO 80610 11. Description of Waste Materials 12. Coniamers 13. Total 14. Unit No. Tyne G Quantity wt./Voi. L Mme- Comments E a. NON REGULATED SOLID —EXCLUDED UST CONTAMINATED SOIL 1. r} '>'J5 E R WM Profile it 133126CO A b. T 0 R WM Profile # C WM Profile # WM Profile # J. Additional Descriptions for Materials listed Above K. Disposal Location ACCT U: N 10039 COST NAME: PALMETTO ENVIRONMENTAL Cell J I Level Grid 15. Special Handling Instructions and Additional Information Purchase Order # 14027 EMERGENCY CONTACT/ PHONE NO.: 1-800-424-9300 24HR TOLL FREE 16. GENERATOR'S CERTIFICATE: I hereby certify that the above -described materials are not hazardous wastes as defined by CFR Part 261 or any applicable state law, have been fully and accurately described, classified and packaged and are in proper condition for transportation ac�prding, to applicable regu `e s. Printed Name Signature "On behalf of" n ^tS D t _ IG� 17. Transporter 1 Acknowledge ens of Receipt of Materials Mflnth oay Year r k ' Printed Name ; ; Signatures-"— ,—�7 Month Day roar a 18. Transporter 2 Acknowledgement of Receipt of Materials a t Printed Name —` —" Sigr,a:ure E Month Day year 19. Certificate of Final Treatment/Disposal A r I certify, on behaibof•tlrea ove listed treatment facility, that to the best of my knowledge, the above -described waste was managed in compliance with all applicable laws, regulations permits and licenses on the dates listed above. i 20. Facility O_+Aer-or-Operator Certification of receipt of non -hazardous materials eyed by this manifest. YntedNam' Signature ntntto-, 1 a "ar White- TREATMENT, STORAGE DISPOSAL FACILITY COPYGENERATOR N� e COPY Yellow- GENERATOR #1 COPY Pink- FACILITY USE ONLY Gold- TRANSPORTER i!1 COPY WWVR9�NON-HAZARDOUS MANIFEST NON -HAZARDOUS MANIFEST 1. Generator's US EPA ID No. Manifest Doc No. 2. Page 1 of 3. Generator's Mailing Address: PI It &r+Virot-si 11A1 L q q 5 yor l 5tree t- De.nver', Co t?,O J 6 4. Generator's Phone 303-825-8117 Generator's Site Address Iitdiferent than mallingl: WELD COUNTY GOVERNMENT 1113 H STREET GREELEY, CO 80631 A. Manifest Number WMNA 10615548 B. State Generator's ID 5. Transporter 1 Company Name 1 *f CU I r VCK;O5 , 37-1 C e.Wc1 Jre t ' CO0. 6. US EPA ID Number C. State Transporter's ID Transporter's Phone 7. Transporter 2 Company Name 8. US EPA ID Number E. State Transporter's ID F. Transporter's Phone 9. Designated Facility Name and Site Address NORTH WELD LANDFILL 40000 WELD COUNTY RD 25 AULT CO 80610 10. US EPA ID Number G. State Facility ID H. State Facility Phone 970-545-5015 G 11. Description of Waste Materials 12. Containers 13. Total quantity 14. Unit wt /vo I" Mist" Comments Nu Type E N E R a. NON REGULATED SOLID —EXCLUDED UST CONTAMINATED SOIL WM Profile # 133126CO \ tQ �C 7/ f J A O R b. WM Profile p c WM Profile lt d. WM Profile If J. Additional Descriptions for Materials Listed Above ACCT # : N 10039 CUST NAME: PALMETTO ENVIRONMENTAL K. Disposal Location Cell Level Grid 15. Special Handling Instructions and Additional Information Purchase Order ff 14027 EMERGENCY CONTACT/ PHONE NO.: 1-800-424-9300 24HR TOLL FREE 16. GENERATOR'S CERTIFICATE: I hereby certify that the above -described materials are not hazardous wastes as defined by CFR Part 261 or any applicable state law, have been fully and accurately described, classified and packaged and are in proper condition for transportation according to applicable regula 'ons. Printed Names Signature "On behalf of" Month Day Year T n 17. Tr sporter 1 Acknowledgement of Receipt of Materials a Prin d Na a �-� Signatur� Month Day year 0 18. Transporter 2 Acknowledgement of Receipt of Materials Printed Name Signature g Month Day Year F IC 19. Certificate of Final Treatment/Disposal I certify, on behalf of thg4hQe listed treatment facility, that to the best of my knowledge, the above -described waste was managed in compliance with all applicable laws, regulations, permits and licenses on the dates listed above. 20. Facilityp�vner or pe tor: ertificatio9tof receipt of non -hazardous materials covgre by this manifest. Prin ame. "-' G' L IGC i Signature --- .�- Mo I 9t Da ./ e r •.,.�- , non, mom, viory ae ,. rnl.lu l t wr r Diue- Utly ttI174I Utt SL LUYY Yellow- GENERATOR Ill COPY Pink- FACILITY USE ONLY Gold- TRANSPORTER N1 COPY r} J WASTE MANAGEMENT NON -HAZARDOUS MANIFEST NON -HAZARDOUS MANIFEST 1. Generator's US EPA ID No. Manifest Doc No. 2. Page 1 of 3. Generator's Mailing Address: )q ! r e'ttp 4r,v I Generator's Site Address lir different than maiungi: WELD A. Manifest Number l! Ors rye -rift COUNTY GOVERNMENT WMNA 10615547 LI 94 8 "t1c k Str•ee-L 1113 H STREET B. State Generator's ID Deyve ', Ci.'O )o6 GREELEY, CO 80631 4. Generator's Phone 303-825-8117 S. Transporter 1 Company Name 7rr•Cop TrvLk,V\ 6. US EPA ID Number C. State Transporter's ID 7 Wa ;F 1141W r - Jd -i •N O. Transporters Phone 7. Transporter 2 Company Name 8. US EPA ID Number E. State Transporters ID 9. Designated Facility Name and Site Address 10. US EPA ID Number F. Transporter's Phone NORTH WELD LANDFILL G. State Facility ID 40000 WELD COUNTY RD 25 H. State Facility Phone 970-545 5015 AULT CO 80610 11. Description of Waste Materials 12. cF'"ers 13. Total 14. Unit No. Type G quantity wt-jVol. i. m5c. Comments E a. NON REGULATED SOLID — EXCLUDED UST CONTAMINATED N SOIL t '1 1 Yc ra c� R WM Profile # 133126CO A b III R WM Profile # I C. WM Profile # d. WM Profile # J. Additional Descriptions for Materials Listed Above IC. Disposal Location ACCT # : N 10039 CUST NAME: PALMETTO ENVIRONMENTAL Cell Level Grid 15. Special Handling Instructions and Additional Information Purchase Order it 14027 EMERGENCY CONTACT / PHONE NO.: 1-800-424-9300 24HR TOLL FREE 16. GENERATOR'S CERTIFICATE: I hereby certify that the above -described materials are not hazardous wastes as defined by CFR Part 261 or any applicable state law, have been fully and accurately described, classified and packaged and are in proper condition for transportation according to applicable regulations. Printed Name s Signature "On behalf of Month Day Year r 17. Transporter I Acknowledgement of Receipt of Materials N Pri t d Nam Sign r 5 M nLF'E rear p 18. Transporter 2 Acknowledgement of Receipt of Materials Printed Name Signature fl Month Day Ycar 19. Certificate of Final Treatment/Disposal a I certify, on behalf of the abo a listed treatment facility, that to the best of my knowledge, the above -described waste was managed in compliance with all applicable I s, regulatio , ermits and licenses on the dates listed above. L 20. Fac•' yOytne or Operator. Certification f receipt of non materials cove by this manifest. Pri Name 1= Signature.,_ _�. ,p Year White- TRFATMFNT STr1 Ar;F nicencei tern iTv rnov ^-^^ • ^«,,yeuow- utivttA1 R Iii COPY ..y Pink- FACILITY USE ONLY Gold- TRANSPORTER #1 COPY .1) / f` r 7 ■M/ -1l-1 ry NON -HAZARDOUS MANIFEST WASTE NEANAOEMEIYT NON -HAZARDOUS MANIFEST 1. Generator's US EPA ID No. Manifest Doc No. 2. Page 101 3. Generator's Mailing Address: erator's Site Address (If different than maaingl: A. Manifest Number LD COUNTY GOVERNMENT 10615557 3 H STREET VGREELEY, WMNA B. State Generator's 10 CO 8O631 4. Generator's Phone 303-825-8117 5..-�Transporter 1 Company Name 6. US EPA ID Number C. State Transporter's ID �Z t t r ✓t t k i s D. Transporter's Phone 7. Transporter 2 Company Name 8. US EPA ID Number E. State Transporter's ID 9. Designated Facility Name and Site Address 10. US EPA ID Number F. Transporter's Phone NORTH WELD LANDFILL G. State Facility ID 40000 WELD COUNTY RD 25 AULT CO 80610 H. State Facility Phone 970-545-5015 11. Description of Waste Materials 12. Containers B. Total 1A. unit No. Type G E a. NON REGULATED SOLID —EXCLUDED UST CONTAMINATED Quantity wt./vol. I. Mist, comments N SOIL R A WM Profile # 133126CO b T 0 R WM Profile # WM Profile # WM Profle q J. Additional Descriptions for Materials Listed Above K. Disposal Location ACCT U: N 10039 CUST NAME: PALMETTO ENVIRONMENTAL CellI level Grid 15. Special Handling Instructions and Additional Information Purchase Order 11 14027 EMERGENCY CONTACT / PHONE NO.: 1-800-424-9300 24HR TOLL FREE 16. GENERATOR'S CERTIFICATE: I hereby certify that the above -described materials are not hazardous wastes as defined by CFR Part 261 or any applicable state law, have been fully and accurately described, classified and packaged and are in proper condition for transportation according to applicable regulations, Printed Nam ✓ 1 Signature "Qp behal»f r ��77 Month txiY year r n 17. Transporter 1 Acknowledgement of Receipt of Materials a iedajne Si r 5 Month Day Year auLi o 18. Transporter 2 Acknowledgement of Receipt of Materials T Printed Name Signature E Month DaY Year 19. Certificate of Final Treatment/Disposal F F I certify, on behalf of the above listed treatment facility, that to the best of my knowledge, the above -described waste was managed in compliance with all applicable laws, regulations, permits and licenses on the dates listed above. 20. Facility Owner or Operator: Certification of receipt of non -hazardous m gals covered by this manifes Pr' ted Na - / SiQ atoll y Alon[h DaY Year i Ite- TREAT ENT, 5 RAGE, DIS 4A FACI ITV COPY Rl _ rrNFonrno rn �n v rcnuw- acntnwiUlt ai COPY Pink- FACILITY USE ONLY Gold- TRANSPORTER #1 COPY aMr�r� WASTE NON -HAZARDOUS MANIFEST MANA EMENT� 1. Generator's US EPA ID No. Manifest Doc No. 2. Page 1 of NON -HAZARDOUS MANIFEST 3. Generator's Mailing Address: Generator's Site Address Ill different than madingl: A. Manifest Number WELD COUNTY GOVERNMENT WMNA 10615549 1113 H STREET 8. State Generator's ID GREELEY, CO 80631 4. Generator's Phone 303-825-8117 . Transporter 1 Company Name `� 6. US EPA ID Number �� ' ��JCf- C. State Transporter's ID 0. Transporter's Phone ' tG'�"' < < 7. Transporter 2 Company Name 8. US EPA ID Number E. State Transporter's ID F. Transporter's Phone 9. Designated Facility Name and Site Address 10. US EPA ID Number NORTH WELD LANDFILL G. State Facility ID 40000 WELD COUNTY RD 25 H. State Facility Phone 970-545-5015 AULT CO 80610 G 11. Description of Waste Materials tz. concainers 13. Total Quant,ty 14. Unit WLN, I. Misc. Comments No. Type E a. NON REGULATED SOLID —EXCLUDED UST CONTAMINATED N SOIL t E !2ri R WM Profile ft 133126CO ! b T I ( 0 I I R WM Profile ft C. I I I I WM Profile ff WM Profile # J. Additional Descriptions for Materials Listed Above K. Disposal Location ACCT #: N 10039 CUST NAME: PALMETTO ENVIRONMENTAL Cell Level Grid 15. Special Handling Instructions and Additional Information Purchase Order ff 14027 EMERGENCY CONTACT! PHONE NO.: 1-800-424-9300 24HR TOLL FREE 16. GENERATOR'S CERTIFICATE: I hereby certify that the above -described materials are not hazardous wastes as defined by CFR Part 261 or any applicable state law, have been fully and accurately described, classified and packaged and are in proper condition for transportation according to applicable regulations. Prin. edNaamee G Signature "On behalf of" Month nay year r 17. Transporter 1 Acknowledgement of Receipt of Materials A P ' ted me Signature Ju Month Da Year 18. Transporter 2 Acknowledgement of Receipt of Materials E ft Printed Name Si nature g Month eay Year 19. Certificate of Final Treatment/Disposal F A I certify, on behalf of the above listed treatment facility, that to the best of my knowledge, the above -described waste was managed in compliance with all applicable laws, regulations, permits and licenses on the dates listed above, 20. Facility Owner or Operator: Cert'fication of receipt of non -hazardous materialcovered by this manifest. / vrint' 'Narne ( ., �� Signa re m nih oay i* A/kitn_ toratlACAIT CTltoflcr n ry - u uc- vuvcnr t vn n1 Wry Yellow- GENERATORCOPY Pink- FACILITY USE ONLY Gold- TRANSPORTER H1 COPY ,,,,, . (i,, "7) ■ M /-1 1-1 l- NON -HAZARDOUS MANIFEST WASTE IAOEM NON -HAZARDOUS MANIFEST 1. Generator's US EPA ID No, Manifest Doc No. 2. Page 1 of 3. Generator's Mailing Address: Pairw�tio ` r.�n j� Generator's Site Address lei different than matsnol: A. Manifest Number 5r,t WELD COUNTY GOVERNMENT 10615551 49`15 llor K 5 t 1113 H STREET WMNA B. State Generator's ID U �nv6r , CO r60',11 o GREELEY, CO 80631 4. Generator's Phone 303-825-8117 5. Transporter 1 Company Name 6. US EPA ID Number C. State Transporter's ID 37 � 4 £ur k Wa - LI S C.) Fr ec,t (:l) D. Transporter's Phone . 7. Transporter 2 Company N me 8. US EPA ID Number E. State Transporter's ID 9. Designated Facility Name and Site Address 10. US EPA ID Number F. Transporter's Phone NORTH WELD LANDFILL G. State Facility ID 40000 WELD COUNTY RD 25 H. State Facility Phone 970-545-5015 AULT CO 80610 11. Description of Waste Materials 12. Containers 13. Total 14. Unit No. Type G Cluanuty wt./Vol. Mkc comments E a. NON REGULATED SOLID — EXCLUDED1. LIST CONTAMINATED N SOIL E J R WM Profile # 133126CO b_ T T 0 R WM Profile IS C. WM Profile IS It d I I WM Profile # J. Additional Descriptions for Materials Listed Above K. Disposal Location ACCT U: N 10039 CUST NAME: PALMETTO ENVIRONMENTAL Cell i Level Grid 15. Special Handling Instructions and Additional Information Purchase Order # 14027 EMERGENCY CONTACT / PHONE NO.: 1-800-424-9300 24HR TOLL FREE 16. GENERATOR'S CERTIFICATE: I hereby certify that the above -described materials are not hazardous wastes as defined by CFR Part 261 or any applicable state law, have been fully and accurately described, classified and packaged and are in proper condition for transportation according to applicable regulations. Printed Name(,,I( �1(� Signature "On behalf of i7r I� W Vr 1 r- JL WW �� Mamh Day Year / ✓ YY�L T a 17. Transporter 1 Acknowledgement of Receipt of Materials n P. to Nam Sig e _ n uh Day Yea, 0 18. Transporter 2 Acknowledgement of Receipt of Materials r Printed Name Signature E Month Day Year 19. Certificate of Final Treatment/Disposal A I certify, on behalf of the above listed treatment facility, that to the best of my knowledge, the above -described waste was managed in compliance with all applicable laws, regulations, permits and licenses on the dates listed above. 1 20. Facility Owner or Operator: Certification of receipt ofnon-hazardou n4rials covered by this manif flrinte amen Sin to i ry n Da• ,} � 1' ear kite- TREATMENT. STORA . ISPnSaM Faro rry rnpv t,. �� o r Pink- FACILITY USE ONLY Gold- TRANSPORTER #1 COPY ■ M r1 l-1 vet NON -HAZARDOUS MANIFEST 1. Generator's US EPA ID No. Manifest Doc No. 2. Page 1 of NON -HAZARDOUS MANIFEST 3. Generator's Mailing Address: Generator's Site Address (if different than mnUing): A. Manifest Number Pal t'es tp £nVi✓vr"rt»et't iI WELD COUNTY GOVERNMENT 10615550 4q45 5 YC,f X 3t 1113 H STREET WMNA B. State Generator's ID Den tr Pv-! CO C GREELEY, CO 80631 4. Generator's Phone 303-825-8117 5. Transpporter 1 Company Name Tie' C.up IruC,J.Y"J 6. US EPA ID Number C. State Transporter's ID 37C . L X50 D.Transporter'sPhone re f 7. Transporter 2 Company Name 8. US EPA ID Number E. State Transporters ID F. Transporter's Phone 9. Designated Facility Name and Site Address 10. US EPA ID Number NORTH WELD LANDFILL G. State Facility ID 40000 WELD COUNTY RD 25 H. State Facility Phone 970-545-5015 AULTCO80610 11. Description of Waste Materials 32. Containers ta. Taal tA. Unit No. Type G Quantity Wt./voL i. Misc. Comments E N a. NON REGULATED SOLID— EXCLUDED UST CONTAMINATED SOIL Y�jrC(,5 E R WM Profile a 133126CO AT b I O I R WM Profile ff WM Profile ff d. � I WM Profile N J. Additional Descriptions for Materials Listed Above K. Disposal Location ACCT # : N 10039 CUST NAME: PALMETTO ENVIRONMENTAL Cell Level Grid 15. Special Handling Instructions and Additional Information Purchase Order If 14027 EMERGENCY CONTACT / PHONE NO.: 1-800-424-9300 24HR TOLL FREE 16. GENERATOR'S CERTIFICATE: I hereby certify that the above -described materials are not hazardous wastes as defined by CFR Part 261 or any applicable state law, have been fully and accurately described, classified and packaged and are in proper condition for transportation according to applicable regulations. Printed Name 1 i,e" �r Signature "On behalf of' i % �p41 Month Day Year o i r R 17. Transporter 1 Acknowledgement of Receipt of Materials A Printed Nam ( \� + Signature)...` C &4 18. Transporter 2 Acknowledgement of Receipt of Materials 11 Printed Name Signature Montn Day Year 19. Certificate of Final Treatment/Disposal I certify, on behalf of the above listed treatment facility, that to the best of my knowledge, the above -described waste was managed in compliance with all applicable laws, regulations, permits and licenses on the dates listed above. 20. Facility Owner or Operator: Certification of receipt of non -hazardous ma r1Is covered by this manifest. ' i ted Na � Uf tkl A�)Year( 1 �61i' \ YArt„ TDEATMENT STORAGE •' , DISPOSAL FACILITY COPY blue- GENERATOR e. COPY Yellow- GENERATOR Ill COPY Pink- FACILITY USE ONLY Gold- TRANSPORTER 141 COPY ■MR/-1/� v NON -HAZARDOUS MANIFEST wnsre MANAGEMEW NON -HAZARDOUS MANIFEST 1. Generator's US EPA ID No. Manifest Doc No. 2. Page 1 of 3. Generator's Mailing Address: Pql me-tto £ytv i or\ ne n*41 Generator's Site Address (it different than madingl: WELD A. Manifest Number q J YorK $t COUNTY GOVERNMENT 1113 WMNA 10615538 Denver Co %OU H STREET GREELEY, CO 80631 B. State Generator's ID 4. Generator's Phone 303-825-8117 S. Transported 1 Company Name Sum Cu() Irv<.X;„c 6. US EPA 10 Number C. State Transporter's ID 37 £ur'e Kit WAY -06b Ff'eJec; D. Transporter's Phone ,k 7. Transporter 2 Company 4ame 8. US EPA ID Number E. State Transporter's ID 9. Designated Facility Name and Site Address io. US EPA ID Number F. Transporter's Phone NORTH WELD LANDFILL G. State Facility ID 40000 WELD COUNTY RD 25 H. State Facility Phone 970-545-5015 AULT CO 80610 11. Description of Waste Materials 12. Contamers u. T«ai la. unit No. Type G E a. NON REGULATED SOLID —EXCLUDED UST CONTAMINATED Quantity W[./Vol. I. M.C. Comments N SOIL E /cbl?;s R WM Profile St 133126CO A b. T f O I R WM Profile p I( c. I WM Profile # ' WM Profile 9 J. Additional Descriptions for Materials Listed Above K. Disposal Location ACCT #: N 10039 CUST NAME: PALMETTO ENVIRONMENTAL Cell Level Grid 15. Special Handling Instructions and Additional Information Purchase Order it 14027 EMERGENCY CONTACT / PHONE NO.: 1-800-424-9300 24HR TOLL FREE 16. GENERATOR'S CERTIFICATE: I hereby certify that the above -described materials are not hazardous wastes as defined by CFR Part 261 or any applicable state law, have been fully and accurately described, classified and packaged and are in proper condition for transportation acpordin to applicable regulations. Printed Name �� Signature "On behalf of" Math Day rear ��; St 0 hey i I a 17. Transporter 1 Acknowledgement of Receipt of Materials a Pgpte Na Sig Day n s M h Year 0 18. Transporter 2 Acknowledgement of Receipt o Materials r Printed Name Signature E Month Day Year F 19. Certificate of Final Treatment/Disposal ` I certify, on behalf of the above listed treatment facility, that to the best of my knowledge, the above -described waste was managed in compliance with all applicable laws, regulations, permits and licenses on the dates listed above. 2 . Facility Qwner or Operator: Certification of receipt of non -hazard ds m erials covered by this manife rated '� £2.) Si at n Nt th1 •^tom aV liite-TRE TMENT, STORAGE, DISP SAL FACILITYCOPy `e nhm-rCNCn u� nm. teuow- uttvtiAJUK ir1 COPY Pink- FACILITY USE ONLY Gold- TRANSPORTER Ill COPY NON -HAZARDOUS MANIFEST NON -HAZARDOUS MANIFEST 1. Generator's US EPA ID No. Manifest Doc No. 2. Page 1 of 3. Generator's Mailing Address: Pq�tnyI f Generator's Site Address (if different than macccr,gi: WELD A. Manifest Number 10615554 nvirpr?m_✓f41 COUNTY GOVERNMENT wMNA 4gg5 York St 1113 H STREET B. State Generator's ID DeV�2Y f C O i0 tl6 GREELEY, CO 4. Generator's Phone 303-825-8117 S. Transporter 1 Company Name TinC -r-- 6. US EPA ID Number C. State Transporter's ID 3'76q [Uf e ka cty � t i$t7}f��r� D. Transporter's Phone 7. Transporter 2 Company Name 8. US EPA ID Number E. State Transporter's ID F. Transporter's Phone 9. Designated Facility Name and Site Address 10. US EPA ID Number NORTH WELD LANDFILL G. State Facility ID 40000 WELD COUNTY RD 25 H. State Facility Phone 970-545-5015 AULT CO 80610 j 11. Description of Waste Materials t2. Containers _____ 13. Total ______ w. unit ______________ Nn. Type G Quantity wt./Vol. 1. Misc. Comments E a. NON REGULATED SOLID — EXCLUDED UST CONTAMINATED N SOIL \ ' E 1/a' R WM Profile # 133126CO A b. T IO R WM Profile # c WM Profile IS d. WM Profile It J. Additional Descriptions for Materials Listed Above K. Disposal Location ACCT #: N 10039 CUST NAME: PALMETTO ENVIRONMENTAL Cell Level Grid 15. Special Handling Instructions and Additional Information Purchase Order If 14027 EMERGENCY CONTACT / PHONE NO.: 1-800-424-9300 24HR TOLL FREE 16. GENERATOR'S CERTIFICATE: I hereby certify that the above -described materials are not hazardous wastes as defined by CFR Part 261 or any applicable state law, have been fully and accurately described, classified and packaged and are in proper condition for transportation according to applicable regulations. Printed Nam{{ (y ( k l t 5tv 1•t�r. {�\ i r Signature "On behalf of" /�1 - Month Day %ear R 17. Transportter1 Acknowledgement of Receipt of Materials A Pririt�d Nark/yE , ` — Signatur \� Month Day Year L)-1--- --- - i G .--'-_ f t 18. Transporter 2 Acknowledgement of Receipt of Materials R Printed Name Signature Moncn Day %ear 19. Certificate of Final Treatment/Disposal A I certify, on behalf of the above listed treatment facility, that to the best of my knowledge the above -described waste was managed in compliance with all applicable laws, regulations, permits and licenses on the dates listed above. /1 20. Facility Owner or Operator: Certification of receipt of non-hazardou ater'a s covered by this manifest. r Print Name „r� j �f fj Signal re 1�r ' m r D v Vear White. TPrATMPhMT GTr1RAGr: rmrcoA[nl rnnrrr, rnnv - ......... _ .. Yellow- OLNLRATOR#I COPY Pink- FACILITY USE ONLY Gold- TRANSPORTER #1 COPY WVZI NON -HAZARDOUS WAS'rte IrtAuua4RMHNT MANIFEST L, uenerawors U5 [PA ID N0. Manifest Doc No. NON•HA2ARDOUS MANEFE:ST 2. Page 1 of 3. Generator's Mailing Address; 'o1'k Generator's Slte Address trdlrEil'a,t then manlpdat WELD A. Manifest Number S!�onr'^�°�t�t.� COUNTY GOVERNMENT wMNA 10615552- 11.13 H STREET B. State Generator's ID fl�Y1yrQ,r1 ?' i$Odll 6 GREELEY, CO 80631 4, Generator's Phone 303-825-8117 S. Transporter 1 Company Name 6. US EPA ID Number ., . '� ' C. State Transporter's rD 7. Transporter 2 Compan Name 3, US EPA ID Number D, Transportees Phone :.. . r f .° ' . ; rl:. , is rr E. State Transporter's ID 9, Designated Facility Name and Site Address 10, US EPA lb Number F. Transporter's Phone ! I .1 .. NORTH WELD LANDFIll, 40000 WELD COUNTY RD 25 ! . G. State Facility ID yr i AULT CO 80610 , . H. State Facility Phone 970545-5015 ,„ 12. Description of Waste Materials 1Z canters .. ' 1a. Total 14. Unit No, T�rpe a. NON REGULATED SOLID — EXCLUDED UST CONTAMINATED 4twnuty Wt./Vol I Comments SOIL WM Profile II 133126C0i:I '' "' I WM Profg :, r efl nr �i: .',, I' i;: Iifl'; :�:: ji�l1' };. reC C. .I t ..t}�. IL WM Profge 6 hi d. '• WMProfbed V. ': , r '. r ,i , ,�r . .; lC.•. .•', f r = : -r-t, --.. J. Additional Descriptions for Materials Listed Above K Disposal posal Location ACCT # : N 10039 COST NAME: PALMETTO ENVIRONMENTAL Call Level �rkt LS. Smclal Hanrilinv Incfn frf•Ir..." ..r..r ea.IHf....-I f..i.........w...• Purchase Order II 14027 EMERGENCY CONTACF/ PHONE NO.: 1-800.424-9300 24HR TOLL FREE 16. GENERATOR'SCERTIFICATE; I hereby certify that the above -described materials are not hazardous wastes as defined by CFR Part 261 or any applicable state law, have been fully and accurate) described, classified and acka ad and are in ercondltkm for trans rtatlon according to nipapplicable regulations, Printed Name ` signature "On behalf of"77 1-..J- If Month Onv �,rts 'ow ira T 17. Transporter 1 Acknowledgement of Receipt of Materials R A P cl Names 9 (? 18. Transporter 2 Acknowledgement of Receipt Y Materials T Printed Name A Mouth I Day 19. Certificate of Final Treatmentf Disposal w I certify, on be above listed treatment fadilty, that to the best of my knowledge, the above -described waste was managed in compliance with all applicable a�vs, regulaans, permits and lk enses on the dates listed above. 20. F iy OwnetIperor:CetJfIcatlon of receipt of non -hazardous rnateria by this manifest, V P ted N Siariature iivi; 5IUHAGE, DISPOSAL FACILITY COPY Glue- G RATOR N2 COPY Yellow- GENERATO COPY Pink- FACILITY USE ONLY Gold -TRANSPORTER #1 COPY vvaI NON -HAZARDOUS MANIFEST 1. Generator's US EPA ID No. Manliest Doc No. NON -HAZARDOUS MANIFEST 2. Page 1 of 3 Generator's Mailing Address: t" Generator's Site Address (a jft., rltthan maeiagla ) A. Manifest Number vr�t :'&t vir"onr'e. WELD COUNTY GOVERNMENT 10615535 Yor 't 1113 H STREET WMNA GREELEY, CO 80631 B. State Generator's ID 4. Generator's Phone 303-825-8117 5. Traspo 1 Company Name 6. US EPA ID Number "'• r . :. , ' i ' '' i�•,1r� ,i ' '' tf '' , I s • 37 Ii C. StateTransporter's ID 7. Transpoorter 2 Company Name 8. US EPA ID Number L ; :. rt' �..': l • n .. E. State Transporter's ID : r 9. Designated Facility Name and Site Address 10, USiEPA ID Number F. Transporter's Phone ........ ;,: ; J.; ..,: t' ' ; fi"; ; °a, NORTH WELD LANDFILL 40000 WELD COUNTYRD 25 ;• :•• G, State Facility ID a,r t ': ;,, • ; :;, . AULT CO 80610 H. State Facility Phase 970-545-5015 :.Av 1� � •J:: � .. :.%, ••S(:rjii.:: • �'Y:' :'. .•1i11 �: .;' .. 1t Description of Waste Materials 1z: Containers'" ysmwl 14. Unit :: G No. type E a, NON REGULATED SOLID — EXCLUDED LIST CONTAMINATED quantity wt./val. I• Mlle, comments N SOIL l ° '+ tJ3 R WM Profile # 133126C0T O i'"• I. R WM Profile#1',." :I i.•; 4! .,p i!!i'i� ;• i,'. :;iii. i " 'J: ^ .11 , Ic '{,!. 'aft!.., ',!i;%+ '�Nt . p;•,. `y,. 1. Additional Descriptions for Materials Listed Above K. Disposal Location ACCT #: N 10039 CUST NAME: PALMETTO ENVIRONMENTAL Cell Level Grid IS. Special Handling Instructions and Additional Information ... Ili:.:1 II:. '!' :rl" Iti Purchase order # 14027 EMERGENCY CONTACT/ PHONE NO.; 1-800-424-9300 24H R TOLL FREE 16. GCNCRATOR'SCERTIFICATC: I herebycertlfy that the above -described materials are not hazardous wastes as defined by CFR Part 261 or any applicable state law, have been fully and accurately described, classified and packaged and are Iii proper condition fortrans ortatbn according to a p Icable regulations. Printed Name /) !r ; � Signature "On behalf of. Maras Day year T 17. Trans orter i Acknowledgement of Receipt of Materials w prime ame e.^lT ��-- Signatur Paunch Dan Year 0 18. Transporter 2 Acknowledgement of Receipt of Materials a Printed Name Signature g Month Dar Year 19, Certificate of Final Treatment/Disposal n r certify, on bets Us bove listed treatment facility, that to the best of my knowledge, the above -described waste was managed in compliance applicable la a, regulntl is, permits and licenses on the dates listed above. with all 20, Faclll ne.Q raton rtifrcatio of receipt of non -hazardous materials c e Is manifest. y Prin rime Signature Ma D ear Qom" White REATMENT, STORAG , DISPOSAL FACILITY COPY Blue- G ATOR #2 COPY Yellow- GENERATOR ff1 COPY/ Pink- FACILITY USE ONLY Gold- TRANSPORTER #1 COPY �� , WORM NON -HAZARDOUS MANIFEST NON -HAZARDOUS MANIFEST 1. Generator's US EPA ID No, Manifest Doc No. 2, Page 1 of 3. Genertor's MalOng Address; Generator's Site Address lri dll.rentthan maaingil pja " A. Manifest Number Y)t/Travu»1ent4( WELD COUNTY GOVERNMENT 10615553 x'1'45 Vor K 1113 H STREET WMNA %dry a;,j (7 +t�1AG-y,' `�" GREELEY, CO 80531 B. State Generator's ID 4. Generators Phone 303-825-8117 S. TapsportariCoipenyName iir� 'yeJGKtr, 6. US EPA ID Number r G State Transporter's ID •i . :r po mpanyName i. Trans rter 2 Co 8, US EPA i0 Number D.Transporter'sphone 1:, ••;; ; ' n+ , .. ,•j;;. E, State TransporteesfD f ,. 9. beslgnated Facility Name and 51te Address 10. US EPA 10 Number F. Transporter's FPhone r ; f. - p. NORTH WELD LANDFILL l 40000 WELD COUNTY RD 25 L'. G. State Facility ID rY t .• AULT CO 80610 H. State Facility Phone 970-545-$015 +E.Y:' 'I�• i'' : :.P.. ':: 'il'R.•. qS' �l.•� 'S. :.% figyp' ,a: L•.r 1t. Description of Waste Materials tz Common is. rot.) 14 unit G lie• E a, NON REGULATED SOLID— EXCLUDED UST CONTAMINATED Quantity wt4vol. L Mlse Comments N SOIL - t145 AWM Profile# 133126C0 :*: tt >_t tr °:y .•'., - ? :! WM Profile # 1 „:•• `.y:. ':., c. ,.. ;.S ,. ;�: , tip: .,,.~ •�'t; ;,,: 1 yi:: .i WMProfNeIf iv.0 ,'a.- 4F f i J. Additional Descriptions for Materials Lhted Above ` K Disposal Location `' '"' ' ::�i ACCT 0: N 10039 CUST NAME: PALMETTO ENVIRONMENTAL 15. Special iandling Instructions and Additional Jnformatlon s•:II •.:11I. '.I,•.:Mt:I;7,>. Purchase orderit 14027 EMERGENCY CONTACT/ PHONE NO,r 1-800-424-9300 24HR TOLL FREE I 16, GENERATOR'S CERTIFICATE, hereby certify that the above -described materials are not hazardous wastes as defined by CFR Part 261 or any applicable state law, have been fully and accurate) described, classified and acka ed and are in proper condition for tran talon a ord) to a )cable regulatior>S, Printed Nam I M 11 , f t Signature "On behalf of" I .,..rT —— ~ u__.a r 17. Transporter 1 Acknowledgement of Receipt of Materials R A Print Nam SI N th s c 18: Transporter Acknowledgement Receipt of Materials TPrinted Name e Signature Month ow 0. 15. Cert(flcate of Final Treatment/Disposal n I certify, on behalf of the above listed treatment facility , that to the best of my knowledge, the above -described wa as managed to compliancewith allapplicable laws, re ulatons,permits and licenses on the dates listed above, 20. Facility Owner or Operator, Certification of rece(pt of non -hazardous m Is covered bynifest, Year lavr,)IUltIuat,UISPOSALFACILITY COPY f31lJG GENERA�'OFAff2 ( Yeibw-GENERATORIt1COPY Pink- FACILITY USE ONLY Gakf- TRANSPORTER #1 Copy „~ NON -HAZARDOUS MANIFEST i. Generator's US EPA ID No. Manifest Doc No, NON -HAZARDOUS MANIFEST 2. Page 1 of .,'::1 Pa•:: i. Ali lit it i,' i, I., 3. Generator's Mating Address t ` 's+ Site Address Is itarentthan ntaII1r,j Gene oz��Q A. Manifest Number tail "G' d'tPnviFanrn�n j ,�� k L+ tTimi-sC ve -nment 10108506 49.14 1f or K Street 1 Fi13• •, 14 $ de, WMNA B, State Generator's I D r�'8,F"11ii dr; ( -011190,All (y /�r' 1 i'yy11 � 4. Generator's Phone C -•r ..Izi, l'. • Ii ,,, lmi�t;2!•t:9a C irl%0N 63� :ti: • In� .'. t F �Lwl-HeTransporter 1 Company Name f`n L4 -/a 6. US EPA ID Number :s ,° ` :;: ; ,i,;.tl' ; zi ? . , ;�ti rfrf "lair ,•" C. State trans artar's ID ;r::' _ , IA A Ii D.Transporter's Phone T' ,sire 1 7. Transporter 2 Company N e B US EPA ID Number :_r• ;.. i uG ;rtrtr)+ raq. (tr ., , E. State Transporter's ID 7C:1 i' rls .n:c, ¼1 , r;,•. Rwlh.. 9. DesignatedFadl Name and Site Addressf.Transporter'sPhone 10. US EPA ID Number .;.eia`•I�u� ' : •:' • V, fl:, .• .i ' i'; ";G;,'r }}1�. ,.>'„'• ; �fii�f`r.�"1'I�Wr�(.r" 'LyI•� � � t G. State Facilit ID v 4 D 10 WED Covnt'y Rcd 0- i:: 1: 'I''•,,'t' . ..11 .,1/1-,'�j �. H. State Facgity Phone 303-6444335 1r ••• ' '. 'al:..lsi '•,1 '.irti -. ;. j�, ' y 11. Description of Waste Materials 12. Coetainars 13. Tota! 14. Unit fb nypa 4usn<k1' wt/VaL L G Mrs%Cammanb a'*n Re 00-ed Soli -%alclix&) 1):5rCoMMam►ngte 'c I /N, +401 WMProfi!e# •i� E 'U'+i •r.i y ;, .,�.: ,~7 '' R b. 'l:l•., r•... .' A ' 3'.'j ' i` 1•' d'.,i. ''1.1.1'.' T WM Profile # t'tr'I I; ,! ,,1,•':' :?I'i'i: :i R C. k?: nrrl�' ?li ' ... . .••'' :t., ,I;. ..'' 117,-x'!' WMProffie# :;,:.r Jl; A ,,a N • ' �. ';.It .,k6•_ Y ' :y "' REGULATORY AGENCY: Colorado Department of Public Health and Environment 4300 Cherry Creek Drive South f, c;. ! ; r'ti. ;q:,li i' t l ' , r t Denver, CO 80722-1530 J. Additional Descriptions for Materials Listed Above K. Disposal Location ACCOUNT#: CUSTNAME: pCtti•+t4{,t7trY)Uifanmedr) N 10039 Cell Level Grid 15, Special Handling Instructions and Additional Information Purchese0rder# 1N{�}ca :1. .. p;t,ilit;, EMERGENCY CONTACT/PHONE NO,: 1-800-424•-9300 24HRTOLLFREE 16, GENERATOR'S CERTIFICATE: I hereby certify that the above -described materials are not hazardous wastes as defined by CFR Part 261 or any applicable state law, have been fully and accurately described, classified and packs ed and are In proper condition for transportation according to applicable regulations. Printed N me x.Signature " n behalf of" Month oat Year I^' i 17. Transporter 1 Ac owledgernent of Receipt of Materials T A Pri ted hlyme ` '�� Signet e M«,[b n�V Year 0 1 i. Transporter 2 Acknowledgement of Receipt of Materials T Printed Name Signature MMalth Day Ymif E 19. Certificate of Final Treatment/bisposal n c I certify, on behalf of the above listed treatment facility, that to the best of my knowled the above -described waste was managed in compliance with all applicable laws, regulations, permits and licenses on the dates listed above. 2 FacllIty Owner or Operator: Certification of receipt of non -hazardous teri overed by this manifest T Y tied Signet e I h v vnar ______ Mitt+-TRF TMF:MT. r.MRAGF fllconcAr ChrNl Yry rnev o, _ T enow- utty I:KA t UK fr.00OPY Pink- FACILITY USE ONLY 61TRANSPORTK 111 COPY th _ ua� NON -HAZARDOUS MANIFEST NCNY•HA2ARDQUS MANIFEST 1. Generator's US EPA ID No. Manifest Doc No. r,;.. ;,' rru:"tl'I 2, Page lot 3. Generator's Mafiing Address: J RAImoom v�ronm nto) L4'3 Yank st V 0-nvtrvo7 x 1 g I b 4. Generator's Phone ., „q7t,;, Genera or's Site Address Ir auewe„ tthm metrrng►: ur � nverrnrn.I1 L, 'I°l il' 94 S ode+1 t y. it a A. Manifest Number WMNA 10108504 B. State Generator's ID ., .:; .: . • ;' 5. Transporter 1 Company Name 11t.,1;�+tar i 1 :Fu!y I,:', 7. Transporter 2 Company Name p pay f l m , .; l• lr, t.(' r. Ins .•.. 9, Designated FacIA Name and Site Address i e Novett'+ b[ W rd.� LI"QQ WOOF `,ovnt tW a5 y r! l l �y11 x10 1 1 . 'i6} 6. US EPA ID Number�f , f:"r'.:: r,U.rr'tb„1 8. US EPA ID Number i..'t l :r:[!, k•, 19. US EPA ID Number C. State Trans porter's ID IIa:;! 'ier1 I;:., D. Transporter's Phone 7r ; ; ro; ! ;'I „ .r: n... . E. State Transporter's ID :.r '1'' h:' ,. F, Transporter's Phone a: `rc; r :,?i ari'a.: as C ' :;� GI State Facility ID rr 1.r ls' H. State Factifty Phone 303-644-4335 iy ':: ,.i r 11. Description of Waste Materials E 0.00 - Aeeolq$0IjJ—CItJejJVSTICorl'f+4rY7ir14b+� 5Q 1Z cm Ha s a Is. Total Qwnnty f ' M Unit wt.Wot. I. MIa . cc n ats E WM Profile # W' it' ' i :t:h: l'.r: a, i;IG, ... . ., i,� i ,;i: •',t.r F. , ae1 per r: u,.a R b. c,:i..i. :i.ui A T d O WM Profie9 J. :'I l'i}(t; I is :,:l:' ;r '. f ,. r.ik`f: 'f`}"+': i ,'fl... �'"ry�:q�, '.�i A - .eY;1ri� Y.a`.. gYj. WM Profile # lfYI+:f t 'Ii!': NN- REGULATORY AGENCY: t ?� ;:4 uk �,• p•a . . r ., 1. Colorado Department of Public Health and Environment 4300 Cherry Creek Drive South Denver, Co 80222-1530 i. '' .dl :' ter': Cc- ..:I.! L J. Additional Descriptions for Materials Listed Above N {4O3 aTff: CUST NAME; Pgift'i0-V £nvirbnY'1ehL4) 1. K. Disposal LocationACCOIJN Cell Level Grid -..-. .-,....•.......'.,'•'b ,aw w..uv,w UIR 1`aww,w Vl IC I1,1V,, IICLIV,1 ti;N•^'.. H•arcdli�n+ � .iurai(::e. PurchaseOrder# :'irrt,: ,I,,,er EMERGENCY CONTACT/PHONENO.: 1.800-424-9300 24HRTOLLFREE 16. GENERATOR'S CERTIFICATE: I hereby certify that the above-desrxlbed materials are not hazardous wastes as defined by CFR Part 261. or any applicable state law, have been fully and accurately described, classified and packaged and are n proper condition for transportation accord) to applicable regulations. Printed Name ,( I SIgnature "On behalf of}� Mono, oay Year ,V1YlS Tf1D�,P.r' 11id` A/_ r 17. Transporter I Ackn Nam N � r 18. Transporter 2 Ackni 0 a Printed Name r s g(ca _,rl of Receipt of Materials of Receipt of Materials Signature Month 1. Certificate of Final Treatment/Dispobal n I ce ,ewltirraHe above listed treatment faculty, that to the best of my knowledge, the above -described waste was managed In compliance with all c pplicabfe laws, re ul as, permits and licenses on the dates I adf o e. 20. F ItyOwrrer or tor. Certification of receipt of n hazardous materials ered by this manifest. ENT, STORACF, DISPOSAL FACILITY COPY BlueJGENERATOR 112 COPY Pink- FACILITY USE ONLY Gold -TRANSPORTER #1 COPY I Month I Day Yellow- GENERATOR #1 CQP 41 v n NON -HAZARDOUS MANIFEST NON -HAZARDOUS MANIFEST I. Generator's US EPA ID No, Manifest Doc No. 2. Page lot 3. Generator's Mailing Address; I+v+trc�r' i &Y► ! Genera or's Site Address (tfdlrferentthan tm,ah g)i CAS by CO A, Manifest Number 146 Yor �t ttr r i WY* 11N strut WMNA 10108505 6, state Generator's ID D'I:*I `�St?1 6ii`Nebrr/i'L' A. Generator's Phone C.........., . :; i l .: 5. Transporter 1 Company Name 6. US EPA ID Number r•=;, j' h ,,�: '•,:-. . !' ar i ;:u: ,rr I. ahrl . C. State TransportersID '. p 7. Transporter 2 Company Name 8, USEPAIDNumber D. Transporter's Phone I'l a , r r ;, ;I• I'�; :k. :F.; II I't::irr;.: ''• ii.:' I:.i,•t+N:+'.}r}. E. StateTransporter'sID 9, dasl Hated Facil N y aylmr�e�yla,nnnd Site Address 1D. US EPA ID Number F. Transporters Phone .�I.. s '' ' •' • [ ��:"' 'f•" •(+•'• ,•'.',+: �yis1r-g VI V\."'�.`,/�Ir '11 'yl•�V { r 11 tt i1acli,.' G. State Facility lD I: :.• r ::. •r}•;;: ': 400O0 t� e COun'fiy pill �!J A. ,. . t .. }... H.StateFacilityPhone 303-644-4335 P: :;�j,q •-;ia `It��.•, ::. [ �j ii. •rS�'I .I`'; •. i li,•e" ai�h� '' €:>" e• 1�I r=•. .�:�I`� 11. Description of Waste Materials ]2, Containers 19. Total 14, unit No. Type a•Nort- utJ col;-E%cl (15T Contgrn; nqt Quantity Wt./Vol. I. Mice Commettu a .I;> rbi N �aDt i vr} .d, as / E WMProflleif�'RYfv,bi::tLls: 1;_ . t.,. till t :[ai3s' iii '_ r-' I, i'. I::; ; p . k' b. +y,t. ;n;12 T f rtY O WMProfleff I r.I; ' tiu ; .; R ;.til i. WMProfileI 1"JI E .i'tic 1Ii Ill}: ;},;;. ,.. REGULATORY AGENCY: Colorado Department of publIc Health and Environment 4300Cherry Creek Drive South i; s , F`l't.". a;:.; ; ; ,i,- : Denver, CO 80222-1530 J. Additional Descriptions for Materials Listed Above K. Disposal Location :};y; 'fit'_ 7a 'i '• . N ACCOUNT#: OUST NAME: QA�tn�,{.,p 8r,vii`p�tr'n&"1;,r�) UN� Cell level Grid 15, Special Handling Instructions and Additional Information I':.:i.11i•.I. , .ittt: .rt'.{ PurchaseorderN IRTI€ C :, _; EMERGENCY CONTACT/ PHONE NO.! 1-800-424-9300 24HR TOLL FREE 16. GENERATOR'S CERTIFICATE; I hereby certify that the above -described materials are not hazardous wastes as defined by CFR Part 261 or any applicable state law, have been fully and accurately described, classified and packaged an are in proper condition fortrans ortation ccordln to ppilcabi re ulati Printed Name Signature' on behalf of �-- s. Atanth DnY Year r 17, Transporter 1 Acknowleddement of Receipt of Materials n a Printed Nam �.r— Signature Month Day Year s ..r--Jt a 18. Transporter 2 Acknowledgement of Receipt of Materials w T PYlntedName SI nature g r month Gay Year 19. Certificate of Final Treatment/Olsposal behalf ofth a ve llstad treatment facilit ttl a st of nt knowle the above -described waste was managed incompliance with all laws, regulations, ermits and Ii ion the dates listed above. Owneroro pt qn- eiptofno hazardous materiels c d UY this manifest. Tirt.-T 5iMottth DaY YearATMENT, STORAGE.QISP(ZSAIEACUITVrni'v 1„rnirnnrnna,, .. reirow-UtNtNATURfrCOPY t ' \ Pink FACILITY USE ONLY Gold -TRANSPORTER III COPY 7 W%%VR§6i- NON -HAZARD CJUS MANIFEST i. Genera NONHAZARDOUS MANIFEST 3. Generator's MaiingAddress: '441Vf►'it.'�'!&1 ' viPovt{rt�lfltci� %Votk st i&. 4. Generator's Phone :,....iq:':: 9. Transporter I Company Name 7. Transporter2 Company Name 9. Designated Fa Ilhy NameandSite Address tjor.: 11 t+Jt';' ir. Ci `it' i 11 40aoo W t J County RJ .5 0 31. Desc'iptlon of Waste Materials a. Nov' Reglltqt:; Sol - Xclur r N 601 E WM Proflla # t' �' a b. t`J;. , t::!!:, US EPA ID No. Manifest Doc No, Genera s Site Address (aasre.e,,tt6an marlar)r &4J&&4J&I O�irn► y rn me }4'3 ` 4 Street 6. US EPA ID Number jr B. US EPA ID Number to. US EPA ID Number 2, Page 1 of A. Manifest Number x.0108503 WMNA B. State Generator's ID It.' C, stateTrans orter's1D ra::: r;.,; ..),;g•i,.I II' D,Tra er's Phone Tr'! .:�:r<.p ,,i L 'lit':•. E. StateTransporter's ID ;Itt: • rrii:-r,r;i si; !3Porter's Phone I I'3! a• lr G, State Facility ID ; I', alt'} H. State Facility Phone 303-644.4335 aa. wn.m.lers 43. Total 14. Unit I -- • Type 4uantRy Wtltal, I MIse.corm,ents rda;-: a�L•-rtr�,,: �. iti' � i!xi. i.!'• ': .*y. 7.-r :•rM' ....� .. 7�o WMProfile# Yelp : rr.rF, Ir;,IlI.:- r t;gl r;} !'y, ''i ri;. i/. '. t?'r, WM Profile fi " •i i'i It,: hl!, ,,;.:: i?i i f 4.' 4F REGULATORY AGENCY: Colorado Department of Public Health and Environment •l'•.i 4300 CherryCreek Drive Soutfl I. i ' •` ir1 ;:,i. t;. .! t n . Denver, CO 802T2-1530 J. Additional Descriptions for Materials Listed Above , 'r ,1i.' 1 .:r l ".: ! , II K. Disposal Location ACCOUNT #: CUST NAME: QqI rnrl �" },q �t/iro,'nen iu 100 3� r FiiI Cell level Glad 15. Special Handling instructions and Additional information U11,I PurchaseorderS }4b'rQ:, Ir,': rii;,',, r EMERGENCY CONTACT/PHONENo.: 1-800-424-9300 24HRTOLLI:REE 16, GENERATOR'S CERTIFICATE: I hereby certify that the above -described materials are not hazardous wastes as defined by CFA Part 261 or any applicable state law, have been fully and accurately described, classified and packaged and a In proper condition for transportation ac rding to a licable egul Printed Name Signature "On behalr of" Month Day k65- her • ;f __f 17. Transporter 1 , cknowledgement of Receipt of Materials n A Printed Name - Signature 0 18. Transporter 2 Acknowledgement of Receipt of Materials T Printed Name SI nature E g Month pay 19. Certificate of Final Treatment/Disposal A I certify, an behalf of the above listed treatment facility, that to the best of my knowledge, the above -described waste was managed in compliance with all c applicable laws, regulations, ermits and licenses on the dates listed above, 20. Facility er or Operator: Certifieaton of receipt of non -hazardous m tang red by this manifest. ted me ^ I Slanatu TREATMENT, STCRAGC, DISPOSAL FACILITY copy Blue-GENERA7ORft2COPY Yellow -GENERATOR COPY Pink- FACILITY USE ONLY Gold TRANSPORTER #1 COPY r / f*J4F+�ti.� WWASNON-HAZARDO MENT US MANIFEST 1. Generator's US EPA ID No. Manifest Doc No. NON -HAZARDOUS MANIFEST 2. Page 1 of 3. G`enerator's Mailing Address: PAItmLttD ll Etrrt�irot)•�erlt�r yqq 5 yvc K 5t Dower, CO 9O-.lt, 4. Generator's Phone 303-825-8117 Generator's Site Address lifdifferent than mailing), WELD COUNTY GOVERNMENT 1113 H STREET GREELEY, CO 80631 ' A. Manifest Number WMNA 10615536 B. State Generator's ID 5. Transporter 1 Company Name Ti sCuQTrvck;n j 3 % a kA 4tit Iq (A) 7. Transporter 2 Company Name 9. Designated Facility Name and Site Address NORTH WELD LANDFILL 40000 WELD COUNTY RD 25 AULT CO 80610 6. US EPA ID Number 8. US EPA ID Number 10. US EPA ID Number C. State Transporter's ID D. Transporter's Phone E. State Transporter's ID F. Transporter's Phone G. State Facility ID H. State Facy Phone 970-545-5015 11. Description of Waste Materials 12. Containers 13. Total 14. unit No. Type iIII_ntiiY G E a. NON REGULATED SOLID— EXCLUDED UST CONTAMINATED I. Mir_ Comments SOIL 1� y�trts E R A WM Profile # 133126CO b T O R WM Profile # WM Profile # WM Profile # J. Additional Descriptions for Materials Listed Above K. Disposal Location ACCT #: N 10039 CUST NAME: PALMETTO ENVIRONMENTAL Cell Level Grid 15. Special Handling Instructions and Additional Information Purchase Order # 14027 EMERGENCY CONTACT / PHONE NO.: 1-800-424-9300 24HR TOLL FREE 16. GENERATOR'S CERTIFICATE: I hereby certify that the above -described materials are not hazardous wastes as defined by CFR Part 261 or any applicable state law, have been fully and accurately described, classified and and in packaged are proper condition for transportation accordo applicable regulations. Printed Name " n eh of" �lris �� `Y Month Day Year C Sig toe 1NG t g 17. Transporter 1 Acknowledgement of Receipt of Materials Printed Name Signature Month Day Year a 18. Transporter 2 Acknowledgement of Receipt of Materials e Printed Name Signature Month Day Year 19. Certificate of Final Treatment/Disposal I certify, on behalf of the above listed treatment facility, that to the best of my knowledge, the above -described waste was managed in compliance with all applicable laws, re ulations, permits and licenses on the dates listed above. 20 Facility Owner or Operator: Certification of receipt of non -hazardous m9 rials covered by this manifes .% P rated N l l A Sig toe , (,,,�, oft y ar cite- TREATi ENT, RAGE, DISPOSAL FACILITY COPY 8 on- GFNFRATne if,) rnov Pink- FACILITY USE ONLY Gold- TRANSPORTER Ill COPY 7 i 2.T. TVJ\�-",�aNON-HAZARDOUS MANIFEST NON -HAZARDOUS MANIFEST 1. Generator's US EPA ID No. Manifest Doc No. 2. Page 1 of 3. Generator's Mailing Address: Pc,Irnttto Fnv rov�merttuJ '-H'15 Yor K St Den,,er, Co ;oil 6 IG1L1ey,CO 4. Generator's Phone Generator's Site Address Itt surer nt than maningl: Welc' County ( owtrnr+f6n't, 103 14 Stet 10631 A. Manifest Number WMNA 10108502 B. State Generator's ID 5. Transporter 1 Company Name T.n C1p i r dck;'F"•� 3%L FreJWO Y7 r - -! i ' 6. US EPA ID Number C. State Transporter's ID D. Transporter's Phone 7. Transporter 2 Company ame 8. US EPA ID Number E. State Transporter's ID F. Transporter's Phone 9. Designated Facility Name { and Site Address North Weld L.on4l L4O000 4JC lJ (',uun ty RJ a5 Ault, Cv g06iO 10. US EPA ID Number G. State Facility ID H. State Facility Phone 303-644-4335 11. Description of Waste Materials 12. Containers No. iypc 13. Total Quantity 14. brit Wt./Yal. I. Mist. Comments G E N a. Nay eyUla P S01 - Exclude, UST Ccitf.grrti.nryt $Ot 1 WM Profile N I a o A b WM Profile N 1 / I II R c. WM Profile N ___ f___ ( ! I REGULATORY AGENCY: Colorado Department of Public Health and Environment 4300 Cherry Creek Drive South Denver, CO 80222-1530 J. Additional Descriptions for Materials Listed Above ACCOUNT#: CUST NAME: Pglm2tt0 Envtronrters I N io0 K. Disposal Location Cell J I Level Grid 15. Special Handling Instructions and Additional Information Purchase Order N I `-I d a 7 EMERGENCY CONTACT / PHONE NO.: 1-800-424-9300 24HR TOLL FREE 16. GENERATOR'S CERTIFICATE: I hereby certify that the above -described materials are not hazardous wastes as defined by CFR Part 261 or any applicable state law, have been fully and accurately described, classified and packaged and are in proper condition for transportation according to applicable regulations. Printed Name/ ' U1r } it 1 f`) Signature "On behalf of Month Day Year T 17. Transporter 1 Acknowledgement of Receipt of Materials S Printed Namt�� if Signature I-.�_ r Month Day rear 18. Transporter 2 Acknowledgement of Receipt of Materials Printed Name Signature �Davyea, F c, 19. Certificate of Final Treatment/Disposal I certify, on behalf of the above listed treatment facility, that to the best of my knowledge, the above -described waste was managed in compliance with all applicable laws, regulations, permits and licenses on the dates listed above. 20. Facility O tt r or Ope tor: Certifi ation of receipt of non -hazardous material covered by this manifest. r Printed4ame / TO ATAAC nIT c nonrc n Si nature ; gI Month ay I Year - �•• n1, � 1 . 1 r owc- vuYcnA I vn it t-vvs Yellow- GENERATOR If COPY Pink- FACILITY USE ONLY Gold- TRANSPORTER Iii COPY /``] A VWVM NON -HAZARDOUS MANIFEST 1. Generator's US EPA 10 No. Manifest Doc No. 2. Page 1 of NON -HAZARDOUS MANIFEST 3. Generator's Mailing Address: Palme,tto &n✓.rzo(lMevi a) Genera or's Site Address (if diferentthan mailingl: Weld Covnby Or'' A. Manifest Number 10108507 49g5 Io(K Gtrec;t 1i13 H Stree,6 WMNA B. State Generator's ID 0L'isve_r1 `6o u 2�I, Co `�iOE 1 (hT�,y 4. Generator's Phone S. Transporter 1 Company Name n Cur 1r1'Ck,5' 6. US EPA ID Number C. State _ �p� 3! & a � * 1 L1) fe` eritk CI.DD. Transporter's ID Transporter's Phone 7. Transporter 2 Company Name 8. US EPA ID Number E. State Transporter's ID F. Transporter's Phone 9. Designated Facility Name ad Site Address Not t h we.i LtIZ c.-1 10. US EPA ID Number G. State State Facility ID w� U t ioa�� °'-�f111� �� AvI tI GO H. State Facility Phone 303-644-4335 11. Description of Waste Materials 12. Container Type 13. Total cteantity 14. Unit wt./vol. I. Misc Conents m E pp CC ,.``N.. a' jVofl u ct SC)I . GXJLUOJ 0 �S Ih Cr-id,00 g1,1x F cit E WM Profile # 1 331 ' C ti R b. A WM Profile # R c ( C WM Profile IS ! REGULATORY AGENCY: Colorado Department of Public Health and Environment 4300 Cherry Creek Drive South Denver, CO 80222-1530 I. Additional Descriptions for Materials Listed Above K. Disposal Location ACCOUNT #!!��: CUST NAME: Pu )mett••Cl C,Y7v ronm;4ytte) N Cell Level Grid 15. Special Handling Instructions and Additional Information Purchase Order N s4 o EMERGENCY CONTACT / PHONE NO.: 1-800-424-9300 24HR TOLL FREE 16. GENERATOR'S CERTIFICATE: I hereby certify that the above -described materials are not hazardous wastes as defined by CFR Part 261 or any applicable state law, have been fully and accurately described, classified and packaged and are In proper condition for transportation according to applicable regulations. Printed Nam) Signature "On behalf of'J.._._/'7D Month Day year r R 17. Transporter 1 Acknowledgement of Receipt of Materials y P ted N me T Signature ��. Month Day Year o 18. Transporter 2 Acknowledgement of Receipt of Materials Printed Name Signature Meow Day Year 19. Certificate of Final Treatment/Disposal I certify, on behalf of the above listed treatment facility, that to the best of my knowledge, the above -described waste was managed in compliance with all ` applicable laws, regulations, permits and licenses on the dates listed above. 20. Facility Owner or Operator: Certification of receipt of non -hazardous aterial overed by this manifest. ,/ rnt�d Na - t'r� Sign/ re M Dav rear rL:x rornrnnrn� rrnn,..-r ....-....,-.. �....�..... �...... Pink- FACILITY USE ONLY Dtso- VCINCnH I V,{ Hh t.VYT Gold- TRANSPORTER #1 PY Yellow- 6tNERATOR #1 COPY'" Merchant: ant. Custom Fence & Supply Inc 3031 Hwy 119 Longmont, CO 80504 3036515700 US Order Information Description: 1113 H street Order Number; P.O. Number: Customer ID: PALMETTO ENVIRONMENT Invoice Number: 2021 Billing Information Shipping Information TYLER KALOUS PALMETTO ENVIRONMENTAL GROUP LLC 4995 YORK STREET DENVER, CO 80216 Phone: 9703010607 Shipping: 0.00 Tax: 0.00 Total: USD 990.00 Pment Information Date/Time: Transaction ID: Transaction Type: Transaction Status: Authorization Code: Payment Method: 17 -Aug -2021 09:31:45 MDT 42873938859 Authorization w/ Auto Capture Captured/Pending Settlement 04367G Visa XXXX7670 Petro Waste Solutions LLC 4995 York Street, Unit B Denver, CO 80216-2245 USA Voice: 303-825-8117 Fax: 303-534-5049 Palmetto Environmental Group LLC 4995 York Street Denver, CO 80216 INVOICE Invoice Number: 370 Invoice Date: Aug 24, 2021 Page: 1 Duplicate Weld County Fueling Center 1113 H St Greeley, Co 80632 Customer ID i Customer P0 I Payment Terms Palmetto I Net 30 Days k r Sales Rep ID x Shippingett o p � ' � � Method 41 f Ship I Die Date Hand Deliver 8/17/21 9/23/21 Quantityx 684.00 Item °r Description Excavation and loading (yd3) nit Price f 11.25 Amount 7,695.00 684.00 Transportation of soil > RBLS (yd3) 11.00 7,524.00 684.00 Backfill and compaction, imported (yd3) 12.50 8,550.00 280.00 Asphalt removal and disposal (ft3) 2.50 700.00 -925:00 Concrete removal and disposal (ft3) 3.50 3,237.50 684.00 Transportation of imported soil (trips) 11.00 7,524.00 5.00 Concrete/asphalt trucking (trips) 375.00 1,875.00 80.00 Recycled Asphalt (tons) 23.10 1,848.00 6.00 Recycled Asphalt trucking (trips) 235.00 1,410.00 Subtotal 40, 363.50 Sales Tax Total Invoice Amount 40,363.50 Payment/Credit Applied Theck/Credk Memo No: Petro Waste Solutions LLC 4995 York Street, Unit B Denver, CO 80216-2245 USA Voice: 303-825-8117 Fax: 303-534-5049 Palmetto Environmental Group LLC 4995 York Street Denver, CO 80216 INVOICE Invoice Number: 341 Invoice Date: Sep 2, 2021 Page: 1 Duplicate Weld County Government 1113 H Street Greeley, CO 80631 Palmetto J Waste Manifest #1826 Net 30 Hand Deliver 1 8120121 10/2121 1 PETRO WASTE SOLUTIONS Time And Materials Sheet Weld Co. Government Job Name: 1113 H St Greeley, CO 80631 Description of Work: Excavation Pit Water Removal Date: 8/20/21 • Item Rate Unit Amount Reimbursment F' Taal Odes Mileage 3 Miles 125 9.4 $375.00 Travel Time 75 Hours 5.5 $0.00 On -Site Time 75 Hours 5.5 $0.00 Misc. Field Supplies 25 Day 12.1 $0.00 Mileage DOT Truck 2.75 Miles 9.4 $0.00 Travel Time 80 Hours 13.99 $0.00 On -Site Time 80 Hours 13.99 $0.00 Vacuum Trailer 110 Hours 7.5 13.99 $825.00 Water Disposal 0.6 Gallons 1100 14.3 $660.00 AS/SVE Pilot Test Skid 1,300.00 Day 14.2 $0.00 55 Gallon Waste Oil Drum 55 Drum 14.2 $0.00 Manifest Fee 75 each 1 14.2 $75.00 Part 14.2 $0.00 $0.00 $0.00 Waste Manifest #1826 EID #14027 Removed 1100 gallons 4 PETROWASTE NON -HAZARDOUS WASTE MANIFEST 1826 1. Generator's US EPA ID Number Manifest Document Number 2. Page 1 of 3. Generator's Name and Mailing Address 5. Generating Location (if different) 4. Phone ( ) 6. Phone ( ) l'e C (7 }l ; 7. Transporter #1 Company Name 8. US EPA ID Number 9. Transporter 1`s Phone 10. Transporter #2 Company Name 11. US EPA ID Number 12. Transporter #2's Phone 13. Designated T/S/D Facility Name and Site Address 14. US EPA ID Number 15. Facility's Phone Petro Waste Solutions CO52329-10798 (303) 356-2645 4995 York Street, Suite B Denver, CO 80216 16. Waste Shipping Name and Descrip'on 17. 18. Containers 19. Total 0. Unit I,, __ r ';`-� i ( // f{( ('( l% ix Quantity WWol No. Type Unleaded Gasoline Contaminated Water =V ; . Gallons O I-• b. Diesel Contaminated Water Gallons w z W C7 c. d. 21. Additional Descriptions for Materials Listed Above 22. Special Handling Instructions and Additional Information • 23. GENERATOR'S CERTIFICATION: I certify the materials described on this manifest are not subject to federal regulations for reper)pg proper disposal of Hazardous Waste. Printed+ ped Name Signature j,'./ / Mon Day Year v4`a i. }''1 J i % g.l.' : -ta y'. 24. Transporter #k1: Acknowledgement of Receipt of Materials Printed/Typed Name :' Signature f f Month Day Year O41 •r, / r • �' ..� N 25. Transporter #2: Acknowledgement of Receipt of Materials Q Printed/Typed Name Signature Month Day Year I- 26. Discrepancy Indication Space } H tJ 27. Facility Owner or Operator. Certification of receipt of waste materials covered by this manifest (except as noted in Item 19) D NHWM 06/0 Printed/Typed Name Signature / Month Day Year TDARICDr\ry rn aceAnalytical www pacolabs.com Sold To: John Drafts Palmetto Environmental 4995 York Street Denver, CO 80218 303-825-8117 x107 t N VOl C E Pace Analytical Services, LLC 9608 Lobar Blvd. Pace Analytical Services. LLC 41-1 821 61 7 Lenexa, KS 66219 Pace Analytical National 82-0814289 Phone: (913)599-5665 Pace Analytical Gulf Coast 45-4027089 Invoice Number: 2160141019 Date: 09/1312021 Total Amount Due: $1,955.00 Please Remit To: Pace Analytical Services, LLC P.O. Box 684056 Chicago, IL 60695-4056 S "...F Piu:h@�!(lt�X�P�{�-.%` a 60-5062681 Palmetto Heather Wilson Net 30 Days 1 Client Project 1113 H ST Client Name: Palmetto Pace Project No: 60378343 Sample Received: 8124/2021 Report Sent To: John Drafts, Palmetto Environmental Comments: ANALYTICAL CHARGES Quarri ty Unit Description Method Matrix Price Total 14 Ea 8260 MSV GRO and BTEX EPA 8260 Solid $66.00 $910.00 1 Ea 8260 MSV GRO, BTEX, MTBE EPA 8260 Water $65.00 $65.00 14 Ea TPH-DRO EPA 80158 Solid $70.00 $980.00 Analytical Subtotal $1,955.00 Total Number of Charges 29 Samples Received for analysis: Lab ID_ Client Sample ID Received 60378343001 SC @4' 8/24/2021 7:55:00 60378343002 SECB @ 7' 8/24/2021 7:55:00 60378343003 SWCB @ T 8/24/2021 7:55:00 60378343004 NWCB @ 7' 8/24/2021 7:55:00 60378343005 CB @8' 8/24/2021 7:55:00 60378343008 NWW @ 7' 8/2412021 7:55:00 60378343007 NW -1 @8' 8/24/2021 7:55:00 60378343008 EC t 4' 8/24/2021 7:55:00 60378343009 NW -2 @ 5' 8/24/2021 756.00 60378343010 NCB @ 5' 8/24/2021 7:65:00 60378343011 NEW @ 5' 8/24/2021 7:55:00 Total Invoice Amount $1,955.00 Pagelof2 "*1.5% MONTHLY FINANCE CHARGE ASSESSED AFTER 30 DAYS OR TERMS OF CONTRACT. PACE RESERVES THE RIGHT TO SURCHARGE ON CREDIT CARD PAYMENTS BASED ON CARD TYPE AND ZIP CODE. PLEASE REFERENCE THE INVOICE NUMBER ON ALL REMITTANCE ADVICE. AN EQUAL OPPORTUNITY EMPLOYER Please complete and return copy of invoice with your payment. INVOICE TOTAL $1,955.00 Amount Paid: $ Check No: Customer No: 60-506268 Invoice No: 2160141019 ic aceAnalytical WwNLp8Ce18bs.com L��1Cjt� John Drafts Palmetto Environmental 4995 York Street Denver, CO 80216 303-825-8117 x107 INVOICE Paws Services, LLC 9608 Lolret Blvd. Pace Analytical Services, LLC 41-1821617 Lenexa, KS 66219 Pace Analytical National 62.0814289 Phone: (913)599-5666 Pace Analytical Gulf Coast 45-4027089 Invoice Number: 2160141019 Date: 09/13/2021 Total Amount Due: $1,955.00 Please Remit To: Pace Analytical Services, LLC P.O. Box 684056 Chicago, IL 60695-4056 60-5062681 Palmetto Heather Wilson Net 30 Days 2 Client Project. 1113 H ST Client Name: Palmetto Pace Project No: 60378343 Sample Received: 8/24/2021 Report Sent To: John Drafts, Palmetto Environmental Comments: Samples Received for analysis: Lab ID Client Sample ID Received 60378343012 SWW Q T 8/24/2021 7:55:00 60378343013 SEW @7' 8/24/2021 7:55:00 60378343014 WW @ T 8/24/2021 7:55:00 60378343015 GW-1 8124/20217:55:00 If you have any questions, please contact Heather Wilson at Pace. Phone: 1(913)56.3-1407 Email: heather.wdwn(pacelabs.com Page 2 of 2 "1.5% MONTHLY FINANCE CHARGE ASSESSED AFTER 30 DAYS OR TERMS OF CONTRACT. PACE RESERVES THE RIGHT TO SURCHARGE ON CREDIT CARD PAYMENTS BASED ON CARD TYPE AND 21P CODE. PLEASE REFERENCE THE INVOICE NUMBER ON ALL REMITTANCE ADVICE. AN EQUAL OPPORTUNITY EMPLOYER Petro Waste Solutions LLC 4995 York Street, Unit B Denver, CO 80216-2245 USA Voice: 303-825-8117 Fax: 303-534-5049 Palmetto Environmental Group LLC 4995 York Street Denver, CO 80216 Check/Crec INVOICE Invoice Number: 338 Invoice Date: Aug 24, 2021 Page: 1 Duplicate Weld County Government 1113 H St. Greeley, CO 80631 1.00 VT Excavation Pit water Removal. EID #14027 1,995.00 1,995.00 lit Memo No: Subtotal 1,995.00 Sales Tax Total Invoice Amount 1,995.00 Payment/Credit Applied PETRO WASTE SOLUTIONS Time And Materials Sheet Weld Co. Government Job Name: 1113 H St Greeley, CO 80631 Description of Work: Excavation Pit Water Removal Date: 8/23/21 Item Rate Unit Amount Reimbursmcnt Codes Total Mileage 3 Miles 125 9.4 $375.00 Travel Time 75 Hours 5.5 $0.00 On -Site Time 75 Hours 5.5 $0.00 Misc. Field Supplies 25 Day 12.1 $0.00 Mileage DOT Truck 2.75 Miles 9.4 $0.00 Travel Time 80 Hours 13.99 $0.00 On -Site Time 80 Hours 13.99 $0.00 Vacuum Trailer 110 Hours 7.5 13.99 $825.00 Water Disposal 0.6 Gallons 1200 14.3 $720.00 AS/SVE Pilot Test Skid 1,300.00 Day 14.2 $0.00 55 Gallon Waste Oil Drum 55 Drum 14.2 $0.00 Manifest Fee 75 each 1 14.2 $75.00 Part 14.2 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Total $1,995.00 Waste Manifest #1827 EID #14027 Removed 1200 gallons 6 PETROWASTE SOLUTIONS NON -HAZARDOUS WASTE MANIFEST 1827 1. Generator's US EPA ID Number Manifest Document Number 2. Page 1 of 3. Generator's Name and Mailing Address 5. Generating Location (if different) t j f 4. Phone ( ) 6. Phone ( ) IT , ,: 7. Trans er #1 Company Name l 8. US EPA ID Number 9. Transporter #1's Phone 10. Transporter #2 Company Name 11. US EPA ID Number 12. Transporter #2's Phone 13. Designated T/S/D Facility Name and Site Address 14. US EPA ID Number 15. Facility's Phone Petro Waste Solutions CO52329-10798 (303) 356-2645 4995 York Street, Suite B Denver, CO 80216 16. Waste Shipping Name and Description 17. 18. Containers 19. Total 20. Unit te j { 9 t ) f I f ; C_ 1_l No. Quantity Wt/Vol J.J�L.C L Type a. Unleaded Gasoline Contaminated Water r/ ' Gallons O b. wDiesel Contaminated Water Gallons z 'W o c. d. 21. Additional Descriptions for Materials Listed Above 22. Special Handling Instructions and Additional Information 23. GENERATOR'S CERTIFICATION: I certify the' materials described on this rrgoitesht are not subject to federal regulations for reporting proper disposal of Hazardous Waste. Printed/Typed Name Signature - Month Day Year W24. Transporter #1:'Acknowledgement of Receipt of Materials Printed/Typed Name Signature Month Day Year CL to 25. Transporter #2: Acknowledgement of Receipt of Materials z 4 Printed/Typed Name Signature Month Day Year IY F 26. Discrepancy Indication Space I -I 0 27. Facility Owner or Operator: Certification of receipt of waste materials covered by this manifest (except as noted in Item 19) tt Q NHWM 06/0 to Printed/Typed Name Signature Month Day Year TRANSPORTER %� h geotec1 1 Picking Order No: 616299 Ticket Order Date: 08/25/2021 Gentsch Environmental Equipment, Inc. Customer No: 000000060839 2650 East 40th Avenue Salesperson No: 208 REGION 8 Denver, CO 80205 Account Terms: 1%-i 0/N ET30 Phone 303.320.4764 Fax 303.322.7242 Payment Method: PO sales@geotechenv.com www.geotechenv.com Purchase Ord No: PENDING Placed By: Bryan Mills Email: bryan@palmetto-environmental.com Bill To: PALMETTO ENVIRONMENTAL GROUP LLC Ship To: HOLD FOR PICKUP: GEOTECH ENVIRONMENTAL EQUIPMENT, INC 4995 YORK STREET 2650 EAST 40TH AVE DENVER, CO 80216 DENVER, CO 80205 UNITED STATES OF AMERICA UNITED STATES OF AMERICA PICKUP DATE: TIME: RETURN DATE: TIME: SIGNATURE: SIGNATURE: By signing, I understand and agree to Geotech's Rental Policy Shipping Date Ship Via Bill Frt Carrier # Location 08/26/2021 PICK UP CO Shipping Instructions (303) 825-8117 Qty Required Item No. Picking Qty IFT=d ODate Description UOM ❑ Sequence To Pick 1.00 08-26-2021 R8700004 EA R1A-3 1 RENTAL,SOIL HAND AUGER KIT 3.25'AUGER /' END OF LINE ITEMS Special Instructions Route To Department: R G V Rental Page I of I B DAKOTA DRILLING, INC. 1380 UMATILLA STREET DENVER, COLORADO 80204 (303) 893-2810 Bill To: Palmetto Environmental Group LLC Invoice It: 201789 4995 York Street Invoice Date: 08/27/2021 Denver, CO 80216 Client PO 4 14027 Driller DerekDeIeon Job Location 1113 Id Street Greeley QUANTITY ITEM NO . ... DESCRIiPT ON -' PRICE , ' AMOUNT:: 150 520 Pratte l_erMcxlae/Demohe 3.00 450,00 8 :S4Q Poth¢lin Corfng Uf l►ty Clearance 255.00 .. ." 2,040 .00 150 571? MobtllzatI n / Demobilization 4.50 675.00 130 5t3Q SS,A Drillirs Ems n 2.0 2,860.0€x:: 130 5. Q WeltCbm�le> ian 2" 22.00 2,860 00 10 340 55 GI Drum DOT 17l .; 7a;W. 700 .00 1 517 I]eun i50.00 150.00 Billing Questions: REMITTANCE ADDRESS Akt. 307 -843 -?81,1 1380 Umatilla St, Denver CO F. 303-893-2808 80204 Federal Tax ID # 84-361-7658 Sub Total Amount Applied "" Net 30 "'* AMOUNT DUE 9 735.0 Thank you for your Businessl II From Invoice Date aceAnalytical www.pacelabs.com Sold To: John Drafts Palmetto Environmental 4995 York Street Denver, CO 80216 303-825-8117 x107 INVOICE Pace ��tcet S�i�, LLC 9608 Loiret Blvd. Pace Analytical Services. LLC 41-1821617 Lenexa, KS 66219 Pace Analytical National 62-0814289 Phone: (913)599-5665 Pace Analytical Gulf Coast 45-4027089 Invoice Number: 2160140556 Date: 09/03/2021 Total Amount Due: $1,645.00 Please Remit To: Pace Analytical Services, LLC P.O. Box 684056 Chicago, IL 60695-4056 Client Number/Client lD..:.. Purchase Order No _ Pace ,Project Mgr . ,, , Tersns Page 60-506268/ Palmetto Heather Wilson Net 30 Days Client Project 1113 H ST. Client Name: Palmetto Pace Project No: 60378867 Sample Received: 8/31/2021 Report Sent To: John Drafts, Palmetto Environmental Comments: ANALYTICAL CHARGES Quantity Unit Description Method Matrix Price Total 11 Ea 8260 MSV GRO and BTEX EPA 8260 Solid $65.00 $715.00 1 Ea 8270 MSSV PAH by SIM EPA 8270 by SIM Solid $160.00 $160.00 11 Ea TPH-DRO EPA 8015B Solid $70.00 $770.00 Analytical Subtotal $1,645.00 Total Number of Charges 23 Total Invoice Amount $1,645.00 Samples Received for analysis: Lab ID Client Sample ID Received 60378867001 MW -02R @10'-12' 8/31/2021 9:00:00 60378867002 MW -03R @12'-14' 8/31/2021 9:00:00 60378867003 MW -05 @5'-5.5' 8/31/2021 9:00:00 60378867004 MW -06 @4.5-5' 8/31/2021 9:00:00 60378867005 MW -07 @4.5-5' 8/31/2021 9:00:00 60378867006 MW -08 @4.5-5' 8/31/2021 9:00:00 60378867007 MW -09 @4'-4.5' 8/31/2021 9:00:00 60378867008 MW -09 @10'-12' 8/31/2021 9:00:00 60378867009 MW -10 @4.5'-5' 8/31/2021 9:00:00 60378867010 MW -11 @4.5'-5' 8/31/2021 9:00:00 60378867011 MW -12 @5-5.5' 8/31/2021 9:00:00 Page 1 of 2 1.5% MONTHLY FINANCE CHARGE ASSESSED AFTER 30 DAYS OR TERMS OF CONTRACT. PACE RESERVES THE RIGHT TO SURCHARGE ON CREDIT CARD PAYMENTS BASED ON CARD TYPE AND ZIP CODE. PLEASE REFERENCE THE INVOICE NUMBER ON ALL REMITTANCE ADVICE. AN EQUAL OPPORTUNITY EMPLOYER Please complete and return copy of invoice with your payment. INVOICE TOTAL $1,645.00 Amount Paid: $ Check No: Customer No: 60-506268 Invoice No: 2160140556 GfceAnalj aI www.pacefabs.com Sold To: John Drafts Palmetto Environmental 4996 York Street Denver, CO 80216 303-825-8117 x107 60-506288! Palmetto iNvoIcE Pace Analytical Services, LLC 9608 Lolrot Blvd. Pace Analytical Services, LLC 41-1821617 Lenexa. KS 88219 Pace Analytical National 62-0814289 Phone: (913)699-58fi Pace Analytical Gulf Coast 45.4027089 Client Project: 1113 H ST. Pace Project No: 60378867 Report Sent To: John Drafts, Palmetto Environmental Comments: Invoice Number: 2160140556 Date: 09/03/2021 Total Amount Due: $1,645.00 Please Remit To: Pace Analytical Services, LLC P.O. Box 684056 Chicago, IL 60695-4056 Heather Wilson f Net 30 Days Client Name: Palmetto Sample Received: 8/31/2021 if you have any questions, please contact Heather Wilson at Pace. Phone: 1(913)663-1407 Email: heather. wllsen@pecelabs.com Page 2 of 2 **1.5% MONTHLY FINANCE CHARGE ASSESSED AFTER 30 DAYS OR TERMS OF CONTRACT. PACE RESERVES THE RIGHT TO SURCHARGE ON CREDIT CARD PAYMENTS BASED ON CARD TYPE AND ZIP CODE. PLEASE REFERENCE THE INVOICE NUMBER ON ALL REMITTANCE ADVICE. AN EQUAL OPPORTUNITY EMPLOYER aceAnaly cal www.pecelabs.cam Sold To; John Drafts Palmetto Environmental 4995 York Street Denver, CO 80216 303-825-8117 x107 INVOICE Pace Analytical services, LLC 9608 Lolret Blvd. Pace Analytical Services, LLC 41-1821617 Lenexa, KS 66219 Pace Analytical National 62-0814289 Phone: (913)599.5685 Pace Analytical Gulf Coast 454027089 Invoice Number: 2160140878 Date: 09/10/2021 Total Amount Due: $1,485.00 Please Remit To: Pace Analytical Services, LLC P.O. Box 684056 Chicago, IL 60695-4056 60-5062681 Palmetto Heather WU7son Net 30 Days Client Protect: 1113 H Street Client Name: Palmetto Pace Project No: 80379332 Sample Received: 9/4/2021 Report Sent To: John Drafts, Palmetto Environmental Comments: ANALYTICAL CHARGES Quantity Unit Description Method Matrix Price Total 11 Ea 8015B TPH-DR0 EPA 80158 Water $70.00 $770.00 11 Ea 8260 MSV GRO, BTEX, & MTBE EPA 8260 Water $65.00 $715.00 Total Number of Charges 22 Samples Received for analysis: Lab ID Client Sample ID Received 60379332001 MW -02R 914/20218:40:00 60379332002 MW -03R 9/4/20218:40:00 60379332003 MW -04 9/4/20218:40:00 60379332004 MW -05 9/4120218:40:00 60379332005 MW -06 914/2021 8:40:00 80379332006 MW -07 9/4120218:40:00 60379332007 MW -08 914/20218:40:00 60379332008 MW -09 914120218:40:00 60379332009 MW -10 9/4/20218:40:00 60379332010 MW 11 9/4/2021 8:40:00 60379332011 MW -12 9/4120218:40:00 Analytical Subtotal $1,485.00 Total Invoice Amount $1,485.00 Page 10f2 2 1.5% MONTHLY FINANCE CHARGE ASSESSED AFTER 30 DAYS OR TERMS OF CONTRACT. PACE RESERVES THE RIGHT TO SURCHARGE ON CREDIT CARD PAYMENTS BASED ON CARD TYPE AND ZIP CODE, PLEASE REFERENCE THE INVOICE NUMBER ON ALL REMITTANCE ADVICE. AN EQUALOPP0RTUNnY EMPLOYER Please complete and return copy of invoice with your payment. INVOICE TOTAL $1,485.00 Amount Paid: $ Check No: Customer No: 60-506268 Invoice No: 2160140878 acerial, y ical www.pacala6S.com Sold To: John Drafts Palmetto Environmental 4995 York Street Denver, CO 80216 303-825-8117 x107 INVOICE Pace Analytical Services, LLC 9608 Loiret Blvd Pace Analytical Services, LLC 41-1821617 Lenexa, KS 86219 Pace Analytical National 62-1)614289 Phone: (913)699-5665 Pace Analytical Gulf Coast 45-4027069 Invoice Number: 2160140878 Date: 09/10/2021 Total Amount Due: $1,485.00 Please Remit To: Pace Analytical Services, LLC P.O. Box 684056 Chicago, IL 60695-4056 "'r1�t'itJ� to �r! 60-5062681 Palmetto Heather Wilson Net 30 Days 2 wrenwrojecr: 1113 M street Client Name: Palmetto Pace Project No: 80379332 Sample Received; 9/4/2021 Report Sent To: John Drafts, Palmetto Environmental Comments: if you have any questions, please contact Heather Wilson at Pace. Phone: 1(913)563-1407 Email•, heather.wllson@paacelabs.com Page 2 of 2 **1.5% MONTHLY FINANCE CHARGE ASSESSED AFTER 30 DAYS OR TERMS OF CONTRACT. PACE RESERVES THE RIGHT TO SURCHARGE ON CREDIT CARD PAYMENTS BASED ON CARD TYPE AND ZIP CODE. PLEASE REFERENCE THE INVOICE NUMBER ON ALL REMITTANCE ADVICE. AN EQUAL OPPORTUNtTY EMPLOYER Esther Gesick From: Chris D'Ovidio Sent: Monday, February 7, 2022 3:54 PM To: Esther Gesick Subject: FW: 1113 H St. Reimbursement Applications and Invoices Here is a little more on the process for the reimbursement process Christopher D'Ovidio Accounting Department 1150 O Street Greeley, CO 80632 tel: 970-400-4447 email: cdovidio@co.weld.co.us Confidentiality Notice: This electronic transmission and any attached documents or other writings are intended only for the person or entity to which it is addressed and may contain information that is privileged, confidential or otherwise protected from disclosure. If you have received this communication in error, please immediately notify sender by return e-mail and destroy the communication. Any disclosure, copying, distribution or the taking of any action concerning the contents of this communication or any attachments by anyone other than the named recipient is strictly prohibited. From: John Drafts <JDD@palmetto-environmental.com> Sent: Monday, February 7, 2022 2:57 PM To: Chris D'Ovidio <cdovidio@weldgov.com>; David Springer <dspringer@weldgov.com> Subject: RE: 1113 H St. Reimbursement Applications and Invoices %aution: This email originated; from outside of. Weld County, Government. Do not click links or open attachments unless yourecognizethe sender and know the content is safe, Chris, Thank you for facilitating the signature from the Commissioner. Now that we have that, we will submit the original application to the OPS tomorrow. It usually takes them 2-4 months to review and bring the site in front of the reimbursement fund for approval. Once we receive payment for the other invoices, we will submit those applications and ideally the OPS will approve all funds at the same time following the reimbursement hearing. Thanks, John D. Drafts, PG Palmetto Environmental Group, LLC 4995 York Street Denver, Co 80216 303-825-8117 x 107 (o) 303-356-2645 cell From: Chris D'Ovidio <cdovidio@weldgov.com> Sent: Monday, February 7, 2022 2:51 PM To: David Springer <dspringer@weldgov.com>; John Drafts <JDD@palmetto-environmental.com> Subject: FW: 1113 H St. Reimbursement Applications and Invoices Good Afternoon Please see the attached signature sheets signed by Commissioner Scott James. Can you tell me what the expected turn around is on this? Please let me know if there is anything else I can do. Thanks Christopher D'Ovidio Accounting Department 1150 O Street Greeley, CO 80632 tel: 970-400-4447 email: cdovidio@co.weld.co.us Confidentiality Notice: This electronic transmission and any attached documents or other writings are intended only for the person or entity to which it is addressed and may contain information that is privileged, confidential or otherwise protected from disclosure. If you have received this communication in error, please immediately notify sender by return e-mail and destroy the communication. Any disclosure, copying, distribution or the taking of any action concerning the contents of this communication or any attachments by anyone other than the named recipient is strictly prohibited. From: Chris D'Ovidio Sent: Friday, February 4, 2022 4:43 PM To: David Springer <dspringer@weldgov.com>; John Drafts <JDD@palmetto-environmentaI.com> Subject: RE: 1113 H St. Reimbursement Applications and Invoices Hi John We will have the payments for the invoice out to you on Monday the 8th. I will also have the signature sheets signed on that day as well. Just an item of note the attached request did not have a signature page, so I printed a copy from one of the others. Thanks Christopher D'Ovidio Accounting Department 1150 O Street Greeley, CO 80632 tel: 970-400-4447 email: cdovidio@co.weld.co.us Confidentiality Notice: This electronic transmission and any attached documents or other writings are intended only for the person or entity to which it is addressed and may contain information that is privileged, confidential or otherwise protected from disclosure. If you have received this communication in error, please immediately notify sender by return e-mail and destroy the communication. Any disclosure, copying, distribution or the taking of any action concerning the contents of this communication or any attachments by anyone other than the named recipient is strictly prohibited. From: David Springer <dspringer@weldgov.com> Sent: Thursday, February 3, 2022 4:38 PM To: Chris D'Ovidio <cdovidio@weldgov.com> Cc: John Drafts <JDD@palmetto-environmental.com> Subject: FW: 1113 H St. Reimbursement Applications and Invoices Chris, Can you answer John's question? This is the packet of paperwork I brught up to you the first part of January. David Springer Director, Fleet Services Weld County Government 1399 N. 17th Ave. Greeley, CO 80631 970-400-3513 970-673-5007 cell Confidentiality Notice: This electronic transmission and any attached documents or other writings are intended only for the person or entity to which it is addressed and may contain information that is privileged, confidential or otherwise protected from disclosure. If you have received this communication in error, please immediately notify sender by return e-mail and destroy the communication. Any disclosure, copying, distribution or the taking of any action concerning the contents of this communication or any attachments by anyone other than the named recipient is strictly prohibited. From: John Drafts <JDD@palmetto-environmental.com> Sent: Thursday, February 3, 2022 4:31 PM To: Morgan Tice <mtice@weldgov.com> Cc: David Springer <dspringer@weldgov.com>; Katie Drafts <Katie@ pa lmetto-environmental.com> Subject: RE: 1113 H St. Reimbursement Applications and Invoices Caut This email`o iginatedfromoatsjdevf Weld couhfiy over�lment Do not click links or open attachments iJnl ssyou recbgflzthe sender and know the'eQntnt is safe Good afternoon, Can you please update me on where we stand with having the signature page signed as well as payment for the invoices attached to the previous email? Thanks, John D. Drafts, PG Palmetto Environmental Group, LLC 4995 York Street Denver, Co 80216 303-825-8117 x 107 (o) 303-356-2645 cell From: John Drafts Sent: Friday, January 7, 2022 9:40 AM To: mtice@weldgov.com Subject: FW: 1113 H St. Reimbursement Applications and Invoices Good Morning, David springer requested I also send you these documents related to the cleanup of the fuel release. Please let me know if you have any questions. Thanks, John D. Drafts, PG Palmetto Environmental Group, LLC 4995 York Street Denver, Co 80216 303-825-8117 x 107 (o) 303-356-2645 cell From: John Drafts Sent: Thursday, January 6, 2022 12:02 PM To: David Springer <dspringer@weldgov.com> Subject: FW: 1113 H St. Reimbursement Applications and Invoices 4 David, It likes like Katie sent these to the admin group? The attachments with the dates are reimbursement applications that the Board Chairman will have to sign (page 4 of each application). The other two attachments labeled invoices are the outstanding invoices that need to be paid. Once we receive the checks and signed signature pages associated with the applications we will get all of this submitted to the OPS for reimbursement. Please let me know if you have any questions. Thanks, John D. Drafts, PG Palmetto Environmental Group, LLC 4995 York Street Denver, Co 80216 303-825-8117 x 107 (o) 303-356-2645 cell From: Katie Drafts <Katie@palmetto-environmental.com> Sent: Thursday, January 6, 2022 11:36 AM To: John Drafts <JDD@palmetto-environmental.com> Subject: FW: 1113 H St. Reimbursement Applications and Invoices From: Katie Drafts Sent: Tuesday, November 16, 2021 2:16 PM To: bconnolly@weldgov.com Subject: 1113 H St. Reimbursement Applications and Invoices Hi Barbara, I've attached several items that need to be passed through the County Board of Commissioners. Palmetto has created 3 invoices and reimbursement applications for the remediation work being performed at 1113 H St. Below is the status of each: Invoice #1 — PAID (thank you!) Reimbursement Application 4/7/21— 5/6/21— Needs approval and signature on Page 4 by the Chair — Board of County Commissioners (Aff Proof of Payment has been signed by Palmetto.) Invoice #2 — Both 15040 and 15040Z need to be paid. Reimbursement Application 5/10/21— 6/28/21— Needs approval and signature on Page 4 by the Chair — Board of County Commissioners (Palmetto will sign the Aff Proof of Payment once payment is received.) Invoice #3 — Both 15076 and 15076Z need to be paid. Reimbursement Application 6/30/21— 9/27/21— Needs approval and signature on Page 4 by the Chair — Board of County Commissioners (Palmetto will sign the Aff Proof of Payment once payment is received.) Once payment is received and signature pages are signed and returned, Palmetto will submit all costs over the $10,000 deductible to the Petroleum Storage Tank Fund for reimbursement. Please let me know if you have any questions. Thanks! Katie Drafts Reimbursement Coordinator/Office Manager Palmetto Environmental Group, LLC 4995 York St. Denver, CO 80216 P: 303.825.8117 x.100 www. Pa l metto-E nvi ro n me nta l.co m katie@palmetto-environmental.com PALMETTO ENVIRONMENTAL GROUP LLC Hello