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Q Keller Canyon El Coffin Butte El Ox'Mountain El Newby Island ® Forward <br /> Sanitary'Landfill Landfill Sanitary Landfill Sanitary Landfill Landfill <br /> 901 Bailey Road a 28972 Coffin Butte Road 12310 San Mateo Road 1601 Dixon Landing Road 9999 S.Austin Road <br /> Pittsburg, CA 94565 -Corvallis,.OR 97330 Half Moon Bay,CA 94019 Milpitas,CA'95035 Manteca,CA 95336 <br /> Phone(925)458-9800 Phone(541)745-2018 Phone(650)726-1819 Phone(408)945-2800 Phone(209)982-4298 <br /> Fax(925)458-9891 Fax(541)745-3826 Fax(650)726-9183 Fax(408)262-2871 Pax(209)982-1009 <br /> NON-HAZARDOUS WASTE MANIFEST <br /> GENERATOR WASTE ACCEPTANCE N0. <br /> Headway LRCM rx7faa <br /> MAILING ADDRESS :: <br /> 2M5 W,Maellm Ave <br /> CITY STATE ZIP <br /> ' REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> 3I �rfa,CA 95203 <br /> PHONE 5GLOVES U GOGGLES . O RESPIRATOR . )b HARD HAT <br /> Z 0.0615 ❑TY-VEK ❑ SAFETY VEST. <br /> CONTACT PERSON <br /> Bred.Cctuliom SPECIAL HANDLING PROCEDURES:. <br /> If SIGNATURE OF AUTHORIZED AGENT/TITLE DATE <br /> GENERATOR'S CEknRCATION:I hereby certify that'the above named material Is not a hazardous <br /> waste as defined by 40 GFR Part 261 or 11119 22 of the Calildrnia code of regulat€ons,has been properly <br /> described,classified and packaged,and Is in proper condition tot transportation a-carding to applicable <br /> regulations;AND,If the waste Is a treatment residue of a previously reatrlcted hazardous waste <br /> eublect to the Land Disposal Restrictions,I oertky and warrant that the waste has been treated I In, RECEIVING FACILITY aocordanoe with the requirements of 40 CFR Part 268 and is no longer a hazardous waste as deined by <br /> 40 CFR Part 261. <br /> WASTE TYPE: <br /> X DISPOSAL U SLUDGE <br /> ❑CONSTRUCTION 0 WOOD <br /> 0 DEBRIS ❑OTHER <br /> ❑SPECIAL WASTE <br /> GENERATING FACILITY <br /> 2025 W.Hamltou Avrr 3MCKTON <br /> TRANSPORTER NOTES: VEHICLE LICENSE NUMBER : TRUCK NUMBER <br /> DRESS <br /> 10 <br /> CITY,STATE,ZIP <br /> StO&UMCA 95105 <br /> PHONE END DUMP BOTTOM DUMP. TR N ER <br /> U; U <br /> SIGNATUR OF AUTHORIZED AGENT OR DRIVER DATE ROLL-OFFS FLAT-BED VAN DRUMS <br /> `/o <br /> / CUBIC YARDS <br /> Hereby certify that the above named material has been <br /> accepted and to the best of my knowledge the foregoing DISPOSAf,METHOD: (TO BE COMPLETED BY LANDFILL) <br /> Is true and accurate. <br /> DISPOSE .OTHER <br /> ❑SOIL <br /> REMARKS <br /> O CONSTRUCTION` <br /> FACILITY TICKET NUMBER DEBRIS. <br /> ❑NON-FRIABLE'" <br /> ASBESTOS <br /> I' <br /> S1 . <br /> GN URE OF THORIZI=D AGENT � DATE _ <br /> ❑W <br /> WOOD <br /> i , <br /> GASH <br /> ❑SPECIALOTHER <br /> SCHEDULING MUST BE MADE PRIORTO 3:00 P M.THE DAY PRIORTO;EXP.ECTED ARRIVAL'•ANY UNSCHEDULED LOADS ARE SUBJECT <br /> TO REFUSAL UPON ARRIVAL.ONGOING DAILY DELIVERIES MUST BE SCHEDULED WITH THE LANDFILL THEDAYBEFORE <br /> GEF�.`RATOR COPY j�'1 h�FANIFEST# . 564943. ' <br />