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[:] Keller Canyon El Coffin Butte ❑Ox Mountain ❑ Newby Island IN Forward <br /> anitary ..andfill 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(E50)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 <br /> Fax(209)982-1009 <br /> NON-HAZARDOUS WASTE MANIFEST <br /> GENERATOR <br /> HeadwaterWASTE ACCEPTANCE NO. <br /> MAILING ADDRESS <br /> 2W W.HiMtkfi vc <br /> CITY, STATE,ZIP REQUIRED PERSONAL PROTECTIVE EQUIPMENT . <br /> UI cn.C'h 952(n. <br /> PHONE 50LOVES .a GOGGLES ❑RESPIRATOR : NU HARD HAT <br /> ❑TY--VEK ❑ SAFETY VEST <br /> CONTACT PERSON <br /> 1 t-cow son SPECIAL HANDLING.PAOCEDURES: . <br /> SIGNATURE OF AUTHORIZED AGENT/TITLE DATE <br /> GENERATOR'S CERTIFICATION:I hereby certify that the above named material is nota hazardous <br /> waste as defined by 40 CFR Part 261 or title 22 of the cafiromla 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 treatmant residue of s previously.restricted hazardous waste <br /> accordancebject to withwith the rend gqu re ants of al i40 CFR Partrt 2 8 and is no longer a hazardous wastand warrant that the waste has been eas dafirred.by ted in RECEIVI G FACILITY <br /> 40 CFR Part 261. <br /> WASTE TYPE: <br /> DISPOSAL ❑SLUDGE <br /> Q CONSTRUCTION ❑WOOD <br /> ❑.DEBRIS' ❑OTHER <br /> Ct SPECIAL WASTE <br /> GENERATING FACILITY <br /> 2025 W,Hmeltun Ave <br /> TRANSPORTER ; <br /> Lafir,Truer <br /> NOTES:. VEHICLE LICENSE.NUMgEA TRUCK NUMBER <br /> ADDRESS <br /> 2.710 I,caacnts <br /> CITY,STATE,ZIP1� <br /> PHONE <br /> (2 45&1145 END DUMP BOTTOM DUMP TRANSFER <br /> SIGNATU E OF AUTHORIZED AGENT OR DRIVER DATE ROLL OFFS FLAT-BED VAN DRUMS <br /> 1 4 f <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 <br /> Is true and accurate. DISPOSAL METFIOD: . (TO BE COMPLETED BY LANDFILL) <br /> DISPOSE OTHER <br /> EMARKS o s011 <br /> ❑CONSTRUCTION <br /> FACILITY TICKET NUMBER DEBRIS <br /> ❑NON-FRIABLE <br /> SIGNATURE OF AUTHO ED AGENT DATE ASBESTOS <br /> ❑W60D <br /> ❑ASH . <br /> O SPECIAL:OTHER <br /> SCHEDULING MUST MADE PRIOR-TO 3:00 P.M.THE.DAY PRIORTO EXPECTED'ARRIVAL-ANY UNSCHEDULED LOADS ARE SUBJECT.. <br /> TO REFUSAL UPON ARRIVAL, ONGOING;DAILY•DELIVERIES MUST:6 'SCHEDULED WITH THE'LANDFILL TH:E.DAY BEFORE; <br /> - ; GENEI9AT610CO�'Y MANIFEST.# .�,'# ^4.L 0 <br />