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Keller Canyon,, ❑Coffin Butte ❑Ox Mountain . ❑ Newby Island IN Forward <br /> Sanitary Landfill Landfill . Sanitary Landfill Sanitary Landfill Landfill <br /> 901'Bailey Road 28972 Loffin 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 b4019 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(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 WASTE ACCEPTANCE NO. <br /> Hctdwaltcr EcRomm <br /> MAILING ADDRESS <br /> 2M W,liazd Un Aye <br /> CITY, STATE,ZIP REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> Stkt' tn'CA 95203 GLOVES O GOGGLES Q RESPIRATOR YU HARD HAT <br /> PHONE <br /> 2009 469-0625 O TY VEK Q SAFETY VEST <br /> CONTACT PERSON <br /> BrdtCouscn SPECIAL HANDLING PROCEDURES: <br /> SIGNATURE OF AUTHORIZED AGENT/TITLE DATE <br /> f <br /> GENERATOR'S CERTIFICATION:I hereby comity 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.propedy <br /> described,classified and packaged,and is In proper condition for transportation aroording to applicable <br /> regulations;AND,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 /> ]DISPOSAL ❑SLUDGE <br /> Q CONSTRUCTION ❑WOOD <br /> Q DEBRIS ❑OTHER <br /> O SPECIAL WASTE <br /> GENERATING FACILITY <br /> 2425 W,Hazidtim Ave M�Tt,'Tt N <br /> TRANSPORTER NOTES: VEHICLE LICENSE NUMBER TRUCK NUMBER <br /> Mt:Tt�s • r <br /> ADDRESS 4:,E(o 0 TT <br /> 2710I.t niu Roqrf <br /> CITY, STATE,ZIP <br /> Stofton,CA 95707 <br /> PHONE END DUMP BOTTOM DUMP TRANSFER <br /> i.2 456-1145 , <br /> SIGNATURE OF AUTHORIZED AGENT OR DRIVER DATE ROLL-OFFS FLAT-BED VAN DRUMS <br /> I <br /> CUBIC YARDS <br /> 1 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 /> I I DISPOSE OTHER <br /> REMARKS Q SOIL <br /> ❑CONSTRUCTION <br /> FACILITYTCK T.NUMBER DEBRIS <br /> Q NON-FRIABLE <br /> ASBESTOS <br /> SIGNATU E OFAUTHQRgED AGENT. DATE <br /> � l C]WOOD <br /> I Q ASH <br /> i <br /> 1 <br /> Q SPECIAL OTHER , <br /> SCHEDULING MUST BE MADE PRIORTO 3:00 P.M.THE DAY PRIORTO EXPECTED ARRIVAL-ANY UNSCHEDULED LOADS ARE SUBJECT <br /> f TO REFUSAL UPON ARRIVAL. ONGOING DAILY DELIVERIES MUST BE SCHEDULED WITH THE LANDFILL THE DAY.BEFORE. <br /> GENERATOR COPY MANIFEST# i' 6 /l Q 9 6 <br /> "t V J <br />