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.❑ Keller Canyon ❑Coffin Butte ❑Ox Mountain ❑ Newby Island. IN-Forward <br /> `.`.Sanitary Landfill - Landfill Sanitary Landfill ' SanitaryLandfill ' Landfill <br /> 901 Bailey Road 28972 Coffin Butte Road 12310 San Mateo Road r F�" 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(9 5)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 /> Headwater R�aL>�es , <br /> MAILING ADDRESS <br /> W. SVI Ave' ^ <br /> CITY,STATE,ZIP REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> 3tolkn'CA 95203 <br /> 4GLOVES '0 GOGGLES ' 0 RESPIRATOR , E]HARD HAT <br /> PHONE <br /> Z 46%0625 iD TY VEK ❑ SAFETY VEST. <br /> CONTACT PERSON <br /> BrdtC lilts SPECIAL HANDLING PROCEDURES: <br /> SIGNATURE OF AUTHORIZED AGENT/TITLE DATE <br /> GENERATOR'S CERTIFICATfON:i hereby certify that the above named material Is not a hazardous <br /> waste as defined by 40 CFR Part 261 or tide 22 of the California code of regulations,has been property <br /> described;classified and packaged,and is in proper condition for transportation axording to applicable <br /> regulations:ANO,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 268 and is no longer a hazardous waste as defined by <br /> 40 CFR Part 261. <br /> WASTE TYPE: <br /> X DISPOSAL 0 SLUDGE <br /> 0 CONSTRUCTION 0 WOOD <br /> O DEBRIS 0 OTHER <br /> 6 SPECIAL WASTE <br /> GENERATING FACILITY <br /> Y15 W,Hmeitexi Ave STOC E.'TON <br /> TRANSPORTER NOTES: VEHICLE LICENSE NUMBER TRUCK NUMBER <br /> lV.(ir:Trlaticr <br /> ADDRESS f / <br /> 2710 Loomis R a <br /> CITY,STATE,ZIP <br /> Utodda%CA.45W5 - <br /> [PHONE <br /> END DUMP" BOTTOM DUMP TRANSFER' <br /> 4-56»1145 <br /> SIGNATURE OF AUTHORIZED AGENT OR DRIVER DAT ROLE:-OFFS FLAT--BEDVAN DRUMS <br /> �. ja <br /> CUBIC YARDS <br /> Lby 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 METHOD: (To!3E CQMpI,ETEo BY LANDFILL) <br /> DISPOSE OTHER <br /> EMARKS O SOIL <br /> 0 CONSTRUCTION <br /> FAQ1LI TICKE NU BER DEBRIS, <br /> O NON-FRIABLE <br /> ASBESTOS <br /> SIGN U OF UTO IZEDAGENT TE <br /> 0 WOOD <br /> 0 ASH <br /> t 11 0 SPECIAL OTHER <br /> SCHEDULIkQVUST BE MADE PRIORTO 3:100 RM.THE DAY PRIORY EXPECTED,ARRIVAL•ANY UNSCHEDULED LOADS ARE SUBJECT. <br /> 70 REFUSAL UPON ARRIVAL. ONGOING DAILY DELIVERIES <br /> MUST.".BE.SCHEDULED WITH THE LANDFILL'THE DAY BEFORE: <br /> GENERATOfi COPY MANIFESTT# .,.,C' ,. J.. <br />