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❑ Keller Canypn C1 Coffin Butte ❑Ox Mountain ❑ Newby Island A Forward - <br /> ia SanItarytandfill Landfill Sanitary Landfill Sanitary Landfill Landfill <br /> 901 Bailey Road 28972 Coffin Butte Road 12310 San Mateo Road 1601 Dixon Landing Road 9999 Si 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)458-9891Fax(541)745-3826 Fax(650)726-9183 Fax(408)262=2871 Fax(209)982-1009 <br /> ,f <br /> NON-HAZARDOUS WASTE MANIFEST <br /> GENERATOR <br /> WASTE ACCEPTANCE NO. <br /> MAILING ADDRESS <br /> m we <br /> 6939 <br /> CITY,STATE,ZIP REQUIRED_ PERSONAL PROTI=CTIVE EQUIPMENT <br /> � �cril,�'A 95". <br /> PHONE 4GLOVES ❑GOGGLES ❑RESPIRATOR N❑HARD HAT <br /> 469"%25 0 TY VEK ❑ SAFETY VEST <br /> CONTACT PERSON <br /> Prd.t.Cculsm : SPECIAL HANDLING PROCEDURES: <br /> SIGNATURE OF AUTHORIZED AGENT/TITLE DATE . <br /> i <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,hes been property <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 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 <br /> accordance with the requirements of 40 CFR Part 268 and is no longer a hazardous waste as defined by RECEIVING FACILITY <br /> 40 CFR Part 261, <br /> WASTE TYPE: <br /> DISPOSAL ❑SLUDGE <br /> ❑CONSTRUCTION ❑WOOD <br /> ❑DEBRIS ❑OTHER <br /> ❑SPECIAL WASTE <br /> GENERATING FACILITY <br /> 2W W,HAMIton Ave T� lrll <br /> TRANSPORTER NOTES: VEHICLE LICENSE NUMBER TRUCK NUMBER <br /> ADDRESS <br /> 27101,0Mxis Road <br /> CITY,STATE,ZIP <br /> PHONE <br /> (20Y)45t;-1145 END DUMP BOTTOM DUMP TRANSFER <br /> � - <br /> NATURE,OF AUTHORIZED GENT OR DRIVER DATE ROLL-OFFS FLAT-BED VAN DRUMS <br /> CUBIC YARDS' <br /> hereby certify that the above named material has been <br /> accepted and to the best of my knowledge the foregoing DIS <br /> Is true and accurate. Po$Al.MErHOD: (TO BE COMPLETED BY LANDFILL) <br /> u: .., ".DISP.05E a• OTHER <br /> REMARKS Q SOIL <br /> ❑CONSTRUCTION <br /> FACILITY TICKET NUMBER DEBRIS <br /> O NON-FRIABLE <br /> SIGNATURE OF AUTH AGEN <br /> ,RiZED T DATE ASBESTOS <br /> C1 WOOD <br /> ❑ASH . <br /> ❑SPECIAL OTHER <br /> SCHEDULING MUST BE MADE PRIORTO 3:00 RM.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 /> GENERAT©R.COPY MANIFEST# `5 -A 8 <br /> 00 . <br />