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d,Keller Canyon �E]Coffin Butte ❑Ox Mountain ❑ Newby Island LTJ 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 /> i Phone(925)458-9800" Rhone(541)745-2018 Phone(650)726-1819 Phone(408)945-2800 Phone(209)982-4296 <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 /> a esrxrt it WASTE ACCEPTANCE NO. <br /> MAILING ADDRESS <br /> I u <br /> I CITY;.STATE,ZIP- . <br /> REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> PHONE NGLOVES a GOGGLES. ❑RESPIRATOR -YU HARD HAT <br /> -0625 O TY VEK ❑ SAFETY VEST <br /> CONTACT PERSON <br /> P ft,COWOW SPECIAL HANDLING PROCEDURES: <br /> SIGNATURE,OF AUTHORIZED AGENT I TITLE DATE <br /> GENCF ATOR'S CERTIFICATION:I hereby certify that the abdve named material Is not a hazardous <br /> Waste as defined by 40 CFR Part 261 or title 22 of the Caltfomia cope of regulations,has been properly <br /> described,classified and packaged,and is in proper condition for transportation a-cording to applicable <br /> regulations:AND,it the waste is a treatment residue of a Prevlousty restricted hazardous waste <br /> subject to the Land Disposal Restrictions,I certify and warrant that the waste has been treated in <br /> eccordanee with the requirements of 40 CFR Part 266 and is no longer a hazardous waste as defined by RECEIVING FACILITY <br /> 40 CFR Part 261. <br /> WASTE TYPE: <br /> 15 DISPOSAL ❑SLUDGE <br /> O CONSTRUCTION ❑WOOD <br /> ❑DEBRIS. Q OTHER <br /> U SPECIAL WASTE <br /> GENERATING FACILITY <br /> 2075 W,.H itun Avs <br /> TRANSPORTER NOTES: VEHICLE LICE <br /> Mr. NSE NUMBER TRUCK NUMBER '" <br /> Trtater _ <br /> ADDRESS <br /> 27101-01XmisR / YggI ' <br /> CITY;STATE,ZIP <br /> ZROMon.GA 952J5 <br /> PHONE END DUMP BOTTOM DUMP TRAN FER <br /> 456-1145. <br /> 51GNATUR FAUTHORIZEDAGENTOR DRIVERDATE ROLL-OFFS FLAT BED . VAN DRUMS <br /> -� _ _ ❑ ❑ ❑ ❑ <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 METHOD: (TO BE COMPLETED BY LANDFILL) <br /> DISPOSE : " OTHER <br /> REMARKS Q SOIL. . <br /> 0 CONSTRUCTION <br /> FACILITY TICKET NUMBER - DEBRIS <br /> Q NON-FRIABLE <br /> SIGNATURE OF AUTHORIZED AGENT ASBESTOS <br /> DATE <br /> Q WOOD <br /> ❑ASH <br /> Q SPECIAL OTHER <br /> SCHEDULING MUST BE MADE PRIORTO 3:00 P.M.THE DAY PRIOR TO EXPECTED ARRIVAL•ANY UNSCHEDULED LOADS ARE SUBJECT <br /> TO REFUSAL UPON ARRIVAL. ONGOING DAILY DELIVERIES MUST BE SCHEDULED WITH.TW.E LANDFILL THE DAY BEFORE. <br /> QENERATOR COPY' MANIFPEST# <br /> 5-6,4787 <br /> 647U7 <br />