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f ❑ Keller Canyon DCofffn- Butte ❑Ox Mountain _ ❑ Newby Island L9 Forward <br /> 4 SanitarltLandflll Landfill Sanitary Landfill" Sanitary Landfill Landfill <br /> 901 Bailey Road 28972 Coffin Butte Road 12310 San Mateo Road 1601 Dixon Landing Road 9999 S.Austin Road <br /> K Pittsburg, CA 94565 Corvallis,OR 97330 Half Moon Bay,CA 94019 Milpitas, CA 95035 Manteca,CA 95336 . <br /> i Phone(925)458.9800 <br /> 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 Fax(209)982-1.009 <br /> NON-HAZARDOUS WASTE MANIFEST <br /> GENERAItTOR Ivr <br /> cm <br /> WASTE ACCEPTANCE N0. <br /> MAILING ADDRESS <br /> M vc <br /> CITY,STATE,ZIP REQUIRED PERSONAL PROTECTIVE EQ�U'- <br /> IPUENTMt &Am,CA0UGOGGLES 0 RESPIRATOR ]HARD HAT <br /> PHONE <br /> LOD 469"M25 ❑TY VEK ID SAFETY VEST <br /> CONTACT PERSON <br /> Brett.C Kin SPECIAL HANDLING PROCEDURES: <br /> SIGNATURE OF AUTHORIZED AGENT I TITLE DATE <br /> GENERATOR'S CERTIFICATION:I hereby certify that the above named material Is not hazardous <br /> waste as defined by 40 CFR Part 261 or title 22 of the California code of regulations,has been properly <br /> described,classified and packaged,and is in proper condition for transportation a-.carding to applicable <br /> regulations;AND,If the waste Is a treatment residue of a previously restricted hazardous waste <br /> subject to the land Disposal Restrictions,I certify and warrant that the waste has been treated In RECEIVING`FACILITY <br /> accordance with the requirements of 40 CFR Part 268 and is no longer a hazardous waste as defined by <br /> 40 CFR Part 261. <br /> WASTE TYPE; <br /> DISPOSAL ❑SLUDGE <br /> ❑CONSTRUCTION ❑WOOD <br /> ❑DEBRIS ❑OTHER <br /> O SPECIAL WASTE <br /> GENERATING FACILITY <br /> 2W W,fwelton Ave T�1 <br /> TRANSPORTER NOTES._ VEHICLE LICENSE NUMBER TRUCK NUMBER <br /> ADDRESS I #)Tl Yo C <br /> 2710 T.oaskiis Raad <br /> CITY,STATE,ZIP <br /> Viol t <br /> PHONE END'DUMP BOTTOM DUMP TRAN FER <br /> ((? 456-1145 ❑ <br /> SIGNATUFJE OF AUTHORIZED AGENT OR DRIVER10 <br /> DATE ROLL-OFFS) FLAT-BED VAN DRUMS <br /> CUBIC.YARDS <br /> I hereby.certify that the above named material has been <br /> ,. <br /> accepted and to the best of my knowledge the foregoing <br /> is true and accurate. DlsposAL METHOD: (To BE coMPLi=rED BY LANDFILL) <br /> DISPOSE OTHER <br /> FI <br /> EMARKS ❑SOIL <br /> ❑CONSTRUCTION <br /> FACILITY TIC KET NU BER DEBRIS '. <br /> NOWFRIABLE <br /> SIGNATUFEAUTWIR)ZED AGENT D ASBESTOS <br /> ATE <br /> O WOOD <br /> Ia ASH <br /> ©SPECIAL OTHER <br /> SCHEDULI G MOST BE MADE PRIOR TO 3:00 P.M.THE DAY PRIORTO EXPECTED ARRIVAL•ANY UNSCHEDULED LOADS ARE SUBJECT', <br /> TO REFUS PON ARRIVAL. ONGOING DAILY DELIVERIES MUST BE SCHEDULED WITH THE LANDFILL THE <br /> � / <br /> DAY E <br /> Y BEFOR ; <br /> GENiERA7ORR COPY. MANIFEST V# �. 4 <br />