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Keller Canyon Coffin Butte ❑Ox Mountain ❑Newby Island IN Forward T r <br /> unitary Landfill Landfill Sanitary Landfill Sanitary Landfill Landfill <br /> 901 Bailey Road 28972 Coffin BuM Roads 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 Phone(541)745-2018 Phone(650)726-1819 Phone(408)945-2800 Picone(209)982-4298 <br /> Fax(925)458-9891 Fax(541)745-3826 Fax(650)726-9183 Fax(408).262-2871Z <br /> Fax(t09)982-1009 <br /> 1. -- <br /> ` NON-HAZARDOUS WASTE MANIFEST I <br /> GENERATORt <br /> H idtr RcKxwm WASTE ACCEI PTANCE NO. <br /> MAILING ADDRESS '939- <br /> nazv <br /> CITY;STATE,ZIP <br /> MOMMCA>jzvi REQUIRED PERSONAE.PROTECTIVE EQUIPMENT <br /> PHONE C GLOVES U GOGGLES ❑RESPIRATOR : NQ HARD HAT <br /> ` Q TY VEK a SAFETY VEST <br /> CONTACT PERSON <br /> pixifr;t SPECIAL HANDLING PROCEDURES: <br /> SIGNATURE 01=AUTHORIZED AGENT/TITLE DATE <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 CaIdomia 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 treatment residue of a pravlously 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 /> DISPOSAL U SLUDGE <br /> ❑CONSTRUCTION ❑WOOD <br /> O DEBRIS ❑OTHER <br /> ❑SPECIAL WASTE <br /> GENERATING FACILITY <br /> 2025 WHweltal Ave ft�I+.'TON I <br /> r <br /> r <br /> TRANSPORTER' <br /> NOTES: VEHICLE LICENSE NUMBER T UCK NUMBER <br /> ADDRESS 0 e <br /> 2710 Lama Raat+l i <br /> CITY,STATE,ZIP <br /> PHONE <br /> .456-11END DUMP BOTTOM DUMP TR NSF R <br /> 4 - ❑ <br /> SIGNATURE OF AU. ORIZED AG R 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 <br /> Is true and accurate. DISPOSAL METHOD: (TO BE COMPLETED BY LANDFILL) <br /> DISPOSE BOTHER ` <br /> REMARKS ❑SOIL <br /> ❑CONSTRUCTION <br /> FACILITY TICKET NUMBER DEBRIS. <br /> ©NON-FRIABLE <br /> ASBESTOS <br /> SIGNATUR&OFAUTHjQAIZEDAGENT DATE <br /> o WOOD. <br /> f�J _f�? I ❑ASH <br /> . f <br /> O SPECIAL OTHER <br /> SCHEDULING MUST E M DE PRIORTO3:00 P.M.THE DAY PRIORTO EXPECTED ARRIVAL+ANY UNSCHEDULED LOADS.ARE SUBJECT <br /> TO REFUSAL UPO A IVAL. ONGOING DAILY DELIVERIES MUST BE SCHEDULED WITH,THE,LANDFILL THE <br /> �� / <br /> DAY BEFORE. <br /> CGENERATORCCOPYMANIFEST# U `t Q QV'. <br />