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ur%,erler canyon UCoffin Butte ❑Ox Mountain ❑Newby Island W Forward <br /> Sanitary Landfill Landfill Sanitary Landfill Sar 'ry Landfill Landfill <br /> 901 Bailey Road 28972 Coffin BseRoad 12310 San Mateo Road 160i'm1on 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 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 /> { <br /> NON-HAZARDOUS WASTE MANIFEST <br /> GENERATOR <br /> WASTE ACCEPTANCE NO. <br /> MAILING ADDRESS <br /> 20500 sou%Holly Drive - 9905 <br /> CITY, STATE, ZIP REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> PHONE 23-104 MGLOVES ❑ GOGGLES ❑ RESPIRATOR JID HARD HAT <br /> G N ACT PERSON Q TY-VEK aSAFETY VEST <br /> � SPECIAL HANDLING PROCEDURES: <br /> SIGNATURE OF AUTHORIZED AGENT/TITLE JDATE / <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 in proper condition for transportation according to applicable ' <br /> regulations;AND,If the waste is a treatment residue of a previously restricted hazardous waste 1 <br /> subject to the Land Disposal Restrictions,f certify and warrant that the waste has been treated in RECEIVING FACILITY <br /> accordance with the requirements of 40 CFA Part 268 and is no longer a hazardous waste as defined by - ' <br /> 40 CFR Part 261. <br /> WASTE TYPE: <br /> POSAL ❑SLUDGE <br /> ❑CONSTRUCTION ❑WOOD <br /> ❑DEBRIS ❑OTHER <br /> ❑SPECIAL WASTE ,.. <br /> GENERATING FACILITY <br /> 20500 South Holly Drive TRACY.- <br /> TRANSPORTER <br /> RACY -TRANSPORTER NOTES: VEHICLE LICENSE NUMBER TRUCK NUMBER <br /> ADDRESS RPA Office RM 357 <br /> CJ <br /> CITY, <br /> T.Adi,V.A 95241 <br /> PHONE _ END.DUMP BOTTOM DUMP TRANSFER <br /> ❑ ❑ <br /> SIGNATURE OF AUTHORIZED AGENT OR DRIVER DATE ROLL-OFF(S FLAT-BED VAN DRUMS <br /> ❑ ❑ ❑ ❑ <br /> CUBIC YARD ` <br /> I hereby certify that the above named material has been <br /> accepted and to the best of my knowledge the foregoing <br /> DISPOSAL METHOD:. (TO BE COMPLETED BY LANDFILL) <br /> is true and accurate. <br /> �W DISPOSE OTHER <br /> ❑ SOIL <br /> REMARKS <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 PRIOR TO 3;00 RM.THE DAY PRION TO EXPECTED ARRIVAL■ANY UNSCHEDULED LOADS ARE SUBJECT <br /> TO REFUSAL UPON ARRIVAL. ONGOING DAILY DELIVERIES MUS"f BE SCHEDULED WITH THE LANDFILL THE DAY BEFORE. <br /> Rev 14109 NS-024 GENERATOR COPY MANIFEST#616-212 ',2 <br />