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❑ Keller Canyon ❑Coffin Butte ❑Ox Mountain ❑ Newby island IN Forward <br /> "Sanitaiy Landfill h 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 <br /> Jiro WASTE ACCEPTANCE NO. <br /> :tw ft1 er hc�c+>_1n�x= <br /> MAILING ADDRESS <br /> £I:s; . Alit 69319— <br /> C1TY, STATE,ZIP REQUIRED PERSONAL PROTECTINT <br /> PHONE FN GLOVES U GOGGLES U RESPIRATOR N3 HARD HAT <br /> .L(L4�769-062"; ❑TY VEK U SAFETY VEST <br /> CONTACT PERSON <br /> L►Mt_CvL3hkWj 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 to applicable <br /> regulations;AND,If the waste Is a treatment tesidue 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 /> :b DISPOSAL U SLUDGE <br /> U CONSTRUCTION U WOOD <br /> U DEBRIS U OTHER <br /> ❑SPECIAL WASTE <br /> GENERATING FACILITY <br /> 0251N, T3a.;.elb-I''i,A.v,. <br /> TRANSPORTER NOTES: VEHICLE LICENSE NUMBER TRUCK NUMBER <br /> 14�r.7trlr�t�t. <br /> ADDRESS C(07 7 <br /> 710 LtM11is RCniJ <br /> CITY,STATE,ZIP <br /> PHONE END DUMP BOTTOM DUMP . TRANSFER <br /> SIGNATURE OF AUTHORIZED AGENT OR DRIVER DATE ROLL-OFF(S) FLAT-BED VAN DRUMS <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 /> EMARKS U SOIL <br /> ❑CONSTRUCTION <br /> FACILITY TICKET NUMBER DEBRIS <br /> i U NON-FRIABLE <br /> ASBESTOS <br /> Si NAT RE OF AUTHORIZED AGENT DATE <br /> U WOOD <br /> _� 7 DASHatz( <br /> U SPECIAL OTHER <br /> SCHEDULING MUST-6E MADE PRIOR TO 3:00 P.M.THE DAY PRIORTO EXPECTED ARRIVALS 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# is f` ,1 3® �i <br />� .L <br />