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❑"Keller C,�nyon _ ❑Coffin Butte ❑Ox Mountain ❑ Newby Island ® Forwif~d <br /> r o f <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 996 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 Phore(541)745-2018Phone(650)726-18 19 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 /> 4 <br /> NON-HAZARDOUS WASTE MANIFEST <br /> GENERATOR. WASTE ACCEPTANCE NO. j <br /> Hcaci�ial,�r R�ca> <br /> MAILING ADDRESS <br /> CITY,STATE,ZIP REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> PHONE', N GLOVES U GOGGLES O RESPIRATOR XU HARD HAT <br /> I <br /> 2 U TY-VEK ❑ SAFETY VEST <br /> CONTACT ON CT1 SPECIAL 1 ANDLING PROCEDURES: <br /> SIGNATURE OF AUTHORIZED AGENT/TITLE DATE <br /> E <br /> s Ji <br /> 3 <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 tide 22 of the California 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`ts s treatment residue of a previously restricted hazardous waste <br /> subject to the Land Disposal Restrictions,I certify and warrant that the v7aste has been treated it RECEIVING FACILITY I <br /> accordance with the requirements of 40 CFR Part 266 and is no longer a hazardous waste as defined by <br /> 40 CFR Part 261. <br /> WASTE TYPE: <br /> �0 DISPOSAL ❑SLUDGE <br /> O CONSTRUCTION O WOOD <br /> O DEBRIS O OTHER i <br /> O SPECIAL WASTE <br /> GENERATING FACILITY <br /> 2W W H=Ita1 Avid <br /> TRANSPORTER NOTES: VEHICLE LICENSE NUMBER TRUCK NUMBER <br /> Mr.Tru+*a' <br /> :'. w i <br /> ADDRESS b(0 � . 1 <br /> CITY,STATE,"ZIP <br /> PHONE END DiJ .P BOTTOM DUMP TRANS <br /> Z 45&'11 d <br /> SIGNATURE OF AUTHORIZED AGENT OR DRIVER DATE ROLL-OFFS) FLAT-BED VAN DRUMS <br /> :j <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 /> L METHOD: (TO BE COMPLETED BY LANDFILL <br /> Is true and accurate. DISPOSAL ) <br /> DISPOSE OTHER l j <br /> FI <br /> EMARKS O SOIL . <br /> CONSTRUCTION <br /> FACILITY TICKET NUMBER DEBRIS <br /> O NON-FRIABLE <br /> ASBESTOS <br /> SIGNATURE OFAUTHORIZED AGENT DATE <br /> ❑WOOD <br /> - U ASH <br /> ❑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 THE LANDFILL THE DAY BEFORE 1 <br /> O ENERATOR COPY MANIFEST# 11:89Q { <br /> 1 <br />