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❑ Keller Canyon ., ❑Coffin Butte ❑ Ox Mountain ❑ 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 6939 <br /> I(Qi W,liaw- lum Ave <br /> CITY, STATE,ZIP REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> GLOVES ❑GOGGLES ❑RESPIRATOR NO HARD HAT <br /> PHONE <br /> ❑TY-VEK ❑ SAFETY VEST <br /> CONTACT PERSON <br /> Nrr#I f`oidt rt 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 California code of regulations,has been properly <br /> described,classified and packaged,and is in proper Condition tot transportation a-cording 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 /> 46 CFR Part 261. <br /> WASTE TYPE: <br /> i b DISPOSAL ❑SLUDGE <br /> ❑CONSTRUCTION d WOOD <br /> ❑DEBRIS ❑OTHER <br /> ❑SPECIAL WASTE <br /> GENERATING FACILITY ----- --- ---- - - -- <br /> TRANSPORTER NOTES: VEHICLE LICENSE NUMBER TRUCK NUMBER <br /> Mh TI'l.Ir*rt' r 1. <br /> ADDRESS <br /> -710 LAX�l13.R <br /> CITY,STATE,ZIP <br /> PHONE END DUMP BOTTOM DUMP TRANSFER <br /> (2(Y-J)456-11,45 ❑ ❑ <br /> SIGNATURE OF AUTHORIZED AGENT OR DRIVER DATE ROLL-OFF(S) FLAT-BED VAN DRUMS <br /> CUBIC YARDS <br /> 1 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 /> REMARKS,—, ❑solL <br /> I 1 ❑CONSTRUCTION <br /> FACILITY] ICKETNUMBE DEBRIS . <br /> ❑ NON-FRIABLE <br /> ASBESTOS <br /> SIGNATURE OF UTHO IZED AGENT DATE <br /> ❑WOOD <br /> ❑ASH f <br /> = ❑SPECIAL OTHER <br /> SCHEDULINMUST BE MADE PhIORTO 3:00 P.M.THE DAY PRIOR TO 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 /> GENERATOR COPY MANIFEST# `6 4 7 8 2 <br />