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❑ Keller Canyon ❑ Ox Mountain ❑ Newby Island ❑ Forward <br />' Sanitary Landfill Sanitary Landfill Sanitary Landfill Landfill <br /> 901 Bailey Road 12310 San Mateo Road 1601 Dixon Landing Road 9999 S Austin Road <br /> Pittsburg,CA 94565 Half Moon Bay,CA 94019 Milpitas, CA 95035 Manteca,CA 95336 <br /> Phone (925)458-9800 Phone(650) 726-1819 Phone(408) 945-2800 Phone (209) 982-4298 <br /> Fax(925)458-9891 Fax(650)726-9183 Fax(408) 262-2871 Fax (209)982-1009 <br /> tj <br /> NON-HAZARDOUS WASTE MANIFEST <br />' GENERATOR WASTE ACCEPTANCE NO. <br /> MAILING ADDRESS °a <br /> CITY, STATE, ZIP REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> i <br /> PHONE O GLOVES ElGOGGLES U RESPIRATOR `�U HARD HAT <br /> ❑TY-VEK ❑OTHER <br /> CONTACT PERSON SPECIAL HANDLING PROCEDURES <br /> SIGNATURE OF AUTHORIZED AGENT/TITLE DATE <br /> I <br /> 7�C <br />' GENERATOR S CERTIFICATION I hereby certify that the above named matenat is not a hazardous <br /> waste as defined by 40 CFR Part 261 or dtie 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 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 /> O DISPOSAL ❑SLUDGE <br /> ❑CONSTRUCTION ❑WOOD <br /> ❑DEBRIS ❑OTHER <br /> ❑SPECIAL WASTE <br /> GENERATING FACILITY <br /> oil TRANSPORTER NOTES VEHICLE LICENSE NUMBER TRUCK NUMBER <br /> IADDRESS <br /> CITY, STATE, ZIP <br /> I PHONE END DUMP BOTTOM DUMP TRANSFER <br /> 1 1:1 ❑ <br /> SIGNATURE OF AUTHORIZED AGENT OR DRIVER DATE ROLL-OFF(S) FLAT-BED VAN DRUMS <br /> r <br /> t ❑ ❑ ❑ ❑ <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 DISPOSAL METHOD (TO BE COMPLETED BY LANDFILL) <br /> is true and accurate <br /> DISPOSE OTHER <br /> REMARKS ❑SOIL <br /> ❑CONSTRUCTION <br /> FACILITY TICKET NUMBER DEBRIS <br /> ❑ NON-FRIABLE <br /> ASBESTOS <br /> SIGNATURE OF AUTHORIZED AGENT DATE <br /> ❑ wooD <br />' ❑ ASH <br /> ❑ SPECIAL OTHER <br /> SCHEDULING MUST BE MADE PRIORTO 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 /> r" <br /> eat ee rnav MANIFEST # ,)P ` a <br />