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❑ Keller Canypn ` rQ Coffin Butte ❑Ox Mountain ❑ Newby Island IN 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)726-181,4 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 _ 69649 <br /> CITY, STATE,ZIP REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> GLOVES ❑GOGGLES ❑RESPIRATOR �`❑HARD HAT <br /> PHONE <br /> 'Zoo .,469-w'C"_'� ❑TY VEK ❑ SAFETY VEST <br /> CONTACT PERSON <br /> Br3S tryKA.tlK+ra 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 property <br /> described,classified and packaged,and is in proper condition for transportation a'cording to applicebte <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 266 and is no longer a hazardous waste as defined by <br /> 40 CFR Part 261. <br /> WASTE TYPE: <br /> X65 DISPOSAL ❑SLUDGE <br /> I ❑CONSTRUCTION Q WOOD <br /> Q DEBRIS ❑OTHER <br /> ❑SPECIAL WASTE <br /> GENERATING FACILITY <br /> 20Z5 W,.T.-Ia t-itim Au, aTt ar!I,:1'1:�1�T <br /> I TRANSPORTER NOTES: VEHICLE LICENSE NUMBER TRUCK NUMBER <br /> �Ai:TrA ei- �tfTT�. ( . <br /> ADDRESS dLL)) <br /> CITY, STATE,ZIP <br /> :R"J-ttxa,CA 95205 <br /> PHONE END DUMP BOTTOM DUMP TRANSFER <br /> `2Q )456-1145 ❑ ❑ ' <br /> SIGNATURE OF AUTHORIZED AGENT OR DRIVER DATE ROLL-OFFS FLAT-BED VAN DRUMS <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 /> a <br /> DISPOSE OTHER <br /> ❑SOIL <br /> REMARKS <br /> d <br /> ' CONSTRUCTION _ <br /> DEBRIS <br /> FACILITY TICKET NUMBER <br /> ❑NON-FRIABLE <br /> ASBESTOS <br /> I SIGNATURE QFAU ORIZED AGENT DATE <br /> ❑WOOD <br /> ❑ASH <br /> Q SPECIAL OTHER <br /> A <br /> SCHEDUWNG MUST dE MADE PRIORTO 3:00 P.M.THE DAY PRIORTO EXPECTED ARRIVAL•ANY UNSCHEDULED LOADS ARE SUBJECT <br /> TO'REFUSAL UP6N ARRIVAL. ONGOING DAILY DELIVERIES MUST BE SCHEDULED WITH THE LANDFILL THE DAY BEFORE. <br /> GENERATOR COPY MANIFEST# <br />