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❑ Keller Canyon ❑ oRountain ❑ Newby Island ❑ Forward <br /> Sanitary Landfill Sanitary Landfill Sanitary Landfill Landfill <br /> 901 Bailey Road 12310 San Mateo Road 1601 Dixon Landing Road 9999 S.Austin Road <br /> Pittsburg,CA 94565 Half Moon Bay,CA 94019 Miloltas, CA 95035 Manteca,CA 95336 <br /> Phone(925)458-9800 Phone(650)726.1819 Phone(408)945-2800. Phone(209) 982-4298 <br /> Fax (925)458.9891 Fax(650)726-9183 Fax(408)262-2871 Fax(209)982-1009 <br /> NON-HAZARDOUS WASTE MANIFEST <br /> GENERATOR ' WASTE ACCEPTANCE NO. <br /> t J U nJ Cour% Y 7 _ <br /> MAILING ADD ESS <br /> CITY,STATE,ZIP REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> U r 4 O GLOVES ❑GOGGLES ✓'❑R,E,SPIRATOR ARD HAT <br /> PHONE SR FJ'I S; 0-/_ rjrJ rj <br /> p l0 --- ❑TY-VEK OTHERS _ <br /> CONTACT PERSON SPECIAL HANDLING PROCEDURES: <br /> SIGNATURE OFAUTHORIZEDAGENT/TITDATE <br /> A�/rE I Iz 0-FAIT rawner <br /> * > ` � o i,� <br /> GENERATORS CERTIFICATION:I hereby coney that the above named material is not a hazardous <br /> waste as dented by 40 CFR Pan 261 or tide=of Ne California code of regulations,has been property <br /> described.classified and packaged,and is in proper condition for transportation a-onrding to applicable <br /> reguWtiana;ANO,N the waste Is a treatment residue of a preelously restricted hevrdous waste <br /> 'Tu"t b the taod Disposal Resdicticns,I cenily arM warrant that the waste has been lraaletl in RECEIVING FACILITY <br /> accordance with the recuirements of 4o CFR Pan 266 and is no longer a hazardous waste as defined by <br /> ,to CFR Part 261. <br /> WASTE TYPE: <br /> 0 DISPOSAL O SLUDGE <br /> OCONSTRUCTION O WOOD <br /> -O DEBRIS ❑OTHER <br /> 2fSPECIAL WASTE - <br /> GENERATING FACILITY <br /> � T AB 0 V <br /> TRANSPORTER �( PJV II~ O NOTES: VEHICLELICENSE NUMBER TRUCK NUMBER <br /> ADDRESS rW r Q 76JYS70 1 &T-2 <br /> CITY, STATE,ZIP 00 121 %G <br /> PHONE END DUMP BOTTOM DUMP TRANSFER <br /> ❑ ❑ <br /> SIGNATUREOFAUTHORIZEDAGENTORDRIVER DATE ROL FFS FLAT-BED VAN DRUMS <br /> ❑ ❑ ❑ ❑ <br /> o <br /> CUBIC YARDS <br /> I hereby certify that the above named material has been <br /> accepted and to the best of my knowledge the foregoing DISPOSAL METHOD: (TO BE COMPLETED BY LANDFILL) <br /> is true and accurate. <br /> DISPOSE OTHER <br /> ❑ SOIL <br /> EMARKS ❑CONSTRUCTION <br /> DEBRIS <br /> FACILITY TICKET NUMBER ❑ NON-FRIABLE <br /> ASBESTOS <br /> SIGNATURE OF H0. AGENT DATE O WOOD <br /> O ASH <br /> O SPECIAL OTHER <br /> cru Fnl 11 1Mr;MIJST RF MAOF PRI OR TO 3:00 P.M-THE DAY PRIOR TO EXPECTED ARR IVAL•ANY UNSCHEDULED LOADS ARE SUBJECT <br />