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LJ Keller Canyon Ll Coffin Butte ❑Ox Mountain El Newby Island ®Forward <br /> Sanitary Landfill 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 /> 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 Fax(209)982-1009 <br /> NON-HAZARDOUS WASTE MANIFEST <br /> GENERATOR WASTE ACCEPTANCE NO. <br /> MAILING ADDRESS <br /> 4 CITY, STATE,ZIP REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> Sl. at.c+r�rt'k � C)i U.GLOVES ❑GOGGLES ❑RESPIRATORD HARD HAT <br /> PHONE <br /> a TY VEK ❑ SAFETY VEST <br /> CONTACT PERSON <br /> SPECIAL HANDLING PROCEDURES: <br /> SIGNATURE OF AUTHORIZED AGENT/TITLE DATE <br /> GENERATOR's CERTIFICATION:I hereby certify that the above named material is not a hazardous <br /> waste as defined by 40 CFR Part 261 or title 22 of the Califomia code of regulations,has been properly <br /> described,Classified and packaged,and is In proper condition for transportation a cording b 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 /> .10 DISPOSAL ❑SLUDGE <br /> ❑CONSTRUCTION ❑WOOD <br /> U DEBRIS O OTHER <br /> Q SPECIAL WASTE <br /> GENERATING FACILITY <br /> ZD25-W,TT%mit"a Ave <br /> TRANSPORTER NOTES: VEHICLE LICENSE NUMBER TRUCKNUMBER <br /> ryk �:!-. �t'!!r,}�si' '�.��� 13 �✓�1 �rA�_=� �� <br /> r ADDRESS <br /> CITY,STATE,ZIP <br /> PHONE END DUMP BOTTOM DUMP TRANSFER <br /> !(YJ 45�r-1145 ❑ ❑ <br /> I SIGNATURE OF AUTHORIZED AGENT OR DRIVER DATE ROLL-OFFS FLAT-BED VAN DRUMS <br /> 0 71,11 Ck'Wi , <br /> I <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 /> CI CONSTRUCTION <br /> FACILITY TICKET NUMBER DEBRIS <br /> O NON-FRIABLE " <br /> i <br /> ASBESTOS . <br /> Il <br /> SIGNATURE OF AUTHORIZED AGENT <br /> �o DATE ❑WOOD <br /> ❑ASH <br /> ti r <br /> a SPECIAL OTHER <br /> SCHEDULING MUST BE MADE PR10RT0 3:00 PIM.THE DAY PRIORTO EXPECTED ARRIVAL-ANY UNSCHEDULED LOADS ARE SUBJECT <br /> TO REFUSAL UPON ARRIVAL. ONGOING DAILY DELIVERIES MUST BE SCHEDULED WITH THE LANDFILL THE DAY BEFORE. <br /> OENEfRATfOR COPY MANIFEST# 6,4 <br /> 9 3 3 <br />