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Ll Keller Canyan FE Coffin Butte ❑Ox Mountain ❑ Newby Island ® Forward <br /> Sanitary#'Landfill Landfill Sanitary Landfill Sanitary Landfill Landfill <br /> 901 Bailey Road 28972 Coffi'ri 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 /> CITY,STATE,ZIP REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> Stick tkKi,C GLOVES ❑GOGGLES ❑RESPIRATOR O HARD HAT <br /> PHONE <br /> m5jgo-tk'ir" ❑TY-VEK ❑ SAFETY VEST <br /> CONTACT PERSON SPECIAL HANDLING PROCEDURES: <br /> I3rdt�'csi.►la�: t <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 for transportation a-cordingto applicable <br /> regulations;AND,It the waste Is a treatment residue of a previously restricted ha:erdous 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 GFR 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 /> Q DEBRIS O OTHER <br /> U SPECIAL WASTE <br /> GENERATING FACILITY <br /> TRANSPORTER NOTES: VEHICLE LICENSE NUMBER <br /> „yr�]TRUCK NUMBER <br /> 14f.Tmdam- <br /> ADDRESS <br /> 11 17 <br /> �1'I')I�+.k�atfis tt+gid <br /> CITY, STATE,ZIP <br /> ;'1t�r_1if:,JQ1,td1_9520.1 <br /> PHONE END DUMP BOTTOM DUMP TRANSFER <br /> i.fit �#�ti-]]-t;� ❑ ❑ <br /> SIGNATURE OF AUTHORIZED AGENT OR DRIVER DATE ROLL-OFFS 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) Q <br /> is true and accurate. <br /> DISPOSE OTHER <br /> ❑SOIL <br /> REMARKS <br /> ❑CONSTRUCTION <br /> FACILITY TICKET N MBER l DEBRIS <br /> ❑NON-FRIABLE <br /> ASBESTOS <br /> SIGNATU E OF A THORIZEP AGENT '` DATE <br /> ❑WOOD <br /> -� ❑ASH <br /> ❑SPECIAL OTHER ' <br /> SCHEDULING MUST BE ADE PRIORTO 3:00 P.M.THE DAY PRIORTO EXPECTED ARRIVAL a 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# 5 G 4 7 8 3 <br />