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El Keller Canyon ❑ Coffin Butte ❑Ox Mountain ❑ Newby Island ® 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 /> Phone(925)458-9800 Phoos(5411)145-20118 Phone(650)726-1819 Phone(408)945-2800 Phone(209)982-4298 <br /> ILI Fax(925)458-9891 Fax(541)745-3826 Fax(650)726-9183 Fax(408)262-2871 Fax(209)982-1009 <br /> i' NON-HAZARDOUS WASTE MANIFEST <br /> GENERATOR WASTE ACCEPTANCE-NO. <br /> H�1�1��Rmsx�a <br /> MAILING ADDRESS <br /> 6939 a,N <br /> CITY,STATE,ZIP REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> PHONE GLOVES D GOGGLES , O RESPIRATOR HARD HAT <br /> ate 4 9-0c,754 TY VEK ❑ SAFETY VEST <br /> CONTACT PERSON <br /> Brdt.C'msm SPECIAL HANDLING PROCEDURES,- <br /> SIGNATURE <br /> ROCEDURES:SIGNATURE OF'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 California code of regulations,has been properly <br /> described,classified and packaged,and is Improper condition for transportation&-cording to applicable <br /> regulaflons:AND,if the waste is a treatment residue of s Previously restricted haurdoua waste <br /> sublact to the Land Disposal Reatdotions,I certify and warierd that the waste has been treated in RECEIVING FACILITY <br /> accordance with the requirements of 40 CFR Part 260 and Is no longer a hazardous waste as'defined by <br /> 40 CFR Part 261. <br /> WASTE TYPE: <br /> X DISPOSAL Q SLUDGE <br /> O CONSTRUCTION a WOOD <br /> O DEBRIS 0 OTHER <br /> O SPECIAL WASTE <br /> GENERATING FACILITY <br /> 2OZ5 W,H. citiai Ave 8TQ7Xr0N <br /> TRANSPORTER NOTES. VEHICLE LICENSE NUMBE=R TRUCK NUMBER <br /> W.T"1&Wr <br /> ADDRESS <br /> CITY,STATE,ZIP <br /> Stv+:t,Xt tJA.95405 <br /> PHONE END DUMP BOTTOM DUMP TRANSFER <br /> `20 456-1145 <br /> SIGNATURE QF AUTHORIZED AGENT OR DRIVER DATEI ROLL-OFF(SFLAT-BED VAN DRUMS <br /> i <br /> CUBIC YARDS <br /> 1 hereby certify that the above named material has been <br /> accepted and to the beat of my knowledge the foregoing DISPOSAL METHOD: (TO BE COMOLETED BY LANDFILL) l <br /> Is true and accurate. <br /> DISPOSE OTHER <br /> i <br /> EMARKS O SOIL <br /> O CONSTRUCTION <br /> FACILITY TICKET NUMBER DEBRIS <br /> O NON-FRIABLE <br /> ASBESTOS <br /> SIGNATURE OF AUTHORIZED AGENT DATE <br /> o WOOD4. <br /> , <br /> r <br /> C� 7 ❑ASH <br /> d SPECIALOTHER <br /> SCHEDULING MUST BE 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 BE SCHEDULED,WITH THE LANDFILL THE DAY BEFORE. <br /> a . <br /> GENERATOR CONY MANIFEST# <br /> 564789 . : :. <br />