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1 � r <br /> �■ 3 UNIVERSAL ENVIRONMENTAL <br /> M2 o204 <br /> P.O.BOX 996,BENICIA,CA 94510,(707)747-6699 <br /> NON-HAZARDOUS SPECIAL WASTE MANIFEST <br /> GENERATOR <br /> Generator Name Tenial Transportation Generating Location same <br /> 900 } Victor Rd. <br /> I Address Address <br /> Lodi, CA 95240 <br /> Phone No. 2 0 1-1.3 6 18 1214 7 2 Phone No. h <br /> I Containers Type <br /> —Description of Waste i; ouan'tity Units No. T e C-Drum <br /> � C-Carton <br /> i3-Bag <br /> Contaminated Soil Stith Fuel A (3#1 T -Truck <br /> m El •Pounds <br /> f 8�f Y-Yards:'- <br /> 0-)Other <br /> ards0.Othar <br /> I hereby certify that the above named material does not contain free liquid as~defined by 40 CFR Part 260.10 or any applicable <br /> state taw, is not a hazardous waste as defined by 40 CFR Part 261 or any applicable state law, has been properly described, ' <br /> classified and packaged, and is in'proper condition for transportation according to applicable regulations. <br /> Generator Authorizedeggent Name Signature. <br /> Shipment Date <br /> TRANSPORTER <br /> Truck No. Phone No. '1707-747-6699 <br /> Bnivarsal Environtentatl <br /> Transporter Name Driver Name(Print) <br /> F 1898 Park Road ¢ <br /> Address Vehicle License No./State Ga •e!! << 3// <br /> Benicia,+ CA 94510 — <br /> ' Vehicle Certification <br /> is <br /> I hereby certify that the above named material was picked up I hereby certify that the above named material was delivered with- <br /> at the generator site listed above. out incidenttothe destination listed below. <br /> : Driver Signature __ ✓ 1 r-• (�( Gy.4: C,114 <br /> Shipment Date Driver Signature Delivery Date <br /> .t <br /> DESTINATION <br /> Site Name <br /> Forward Landfill <br /> Phone No ��- <br /> Address 1145 W. Charter way, Stockton, CA 95206 <br /> I by certify that the above named material has been accepted and to the best of my knowledge the foregoing is true and accurate. <br /> Name of Authorized ' ✓ f <br /> Signature' - z Receipt Data <br /> I ---- - <br />