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(J Keller Canyon ❑Coffin 4 tte ❑Ox Mountain ❑Newby Island <br /> [A Forward <br /> Sanitary Landfill Landfill Sanitary Landfill S ry Landfill Landfill <br /> 901 Bailey Road 28972"Coffin Butte Road 12310 San Mateo Road 1601 .Dixon Landing Road 9999 S.Austin Road it- <br /> Pittsburg, CA 94565 Coniallis,OR 97330. Half Moon'Bay, CA 94Q19 Milpitas, CA 95035 Manteca, CA 95336' f <br /> Phone (925)458.9800 Phone,(541) 745 201'8 Phone(650) 726-1819 Phone(408) 945-2800 Phone (209) 982-4298- <br /> Fax(925) 458-9891 f ' Fax(541).745 86�&i Fax(650).726-9183 Fax (408)262-2871 Fax(209)982-1009 <br /> 2 NON-HAZARDOUS WASTE MANIFEST <br /> GENERATOR WASTE ACCEPTANCE NO:`,.;. <br /> MAILING ADDRESS - <br /> 20500 South 968y II]Itave — <br /> CITY, STATE, ZIP REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> ,0A 95304 <br /> PHONE LJTGLOVES O GOGGLES ❑ RESPIRATOR -X HARD HAT ' <br /> 209)834,7679 ❑TY-VEK C SAFETY VEST <br /> CONTACT PERSON <br /> SPECIAL HANDLING PROCEDURES: r <br /> SIGNATURE OF AUTHORIZED AGENT 1 TITLE DATE <br /> /V75 <br /> 4 - <br /> GENERATOR'S GERTIFICATION:I�hereby certify that the above n med material is not a Hazardous Y <br /> . waste as defined by'40 CFR Par1261 or title'22 of the.California code of regulations,has been preperly - - <br /> described,classifiedand 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 <br /> subject to the Land Disposal Restrictions,I certify and warmht that the waste has been treated in RECEIVING F CILITY o J` <br /> •—accordance with the rkdirements of 46 CFR Part 268.and isno longer a-hazardousWaste as defined by <br /> 4a CFR Part 261. <br /> WASTE <br /> sLlUnG <br /> dCONSTRUCTION O WOOD <br /> O DEBRIS Q OTHER <br /> ❑SPECIAL WASTE <br /> GENERATING FACILITY <br /> 20500 901A-116 4y Drive <br /> TRACY <br /> TRANSPORTER NOTES: VEHICLE Lf CENSE NUMBE TRUCK NUMBER <br /> t " <br /> A <br /> Juni I [ » ' - ,gyp <br /> ADDRESS <br /> g <br /> 'CITY, STATE;ZIP <br /> y. <br /> LD4,CA95241 Z. r a <br /> P-HONE : __ �. __ MP- BOTTOM []UMP TRANSFER .. <br /> i <br /> i <br /> SIGNATURE OF-AUTHORIZED AGENT OR DRIVER DATE R LL-OFF(S) FLAT-BED VAN ;DRUMS <br /> . f <br /> CUBIC YARDS <br /> r I hereby certify that the above�A,iamed material has been <br /> accepted and to the best of my Knowledge the foregoing plsl=o METHOD: (TQ BE COMPLETED BY LANDFILL) <br /> is true and accurate. <br /> DISPOSE OTHER <br /> C3 SOIL <br /> REMARKS <br /> ❑ CONSTRUCTION " <br /> k.... <br /> FACILITY TICKET NUMBER, t, DEBRIS❑ NON-FRIABLE <br /> IT AS)3EST S <br /> SIGNATU E OF.AUTHORI D &GLENT DATE <br /> s ❑ W OD <br /> ' U A�H I <br /> ❑ SPECIAL OTHER <br /> SCIiEDULING BE MACRE PR R O 3.00_ P.M.THE DAY PRIOR TO EXPECTED ARRIVAL•ANY UNSCHEDULED LOADS ARE SUBJECT � <br /> TO REFUSAL UPON ARRIVAL. [ YO <br /> DAILY DELIVERIES MUST BE SCHEDULED WITH THE LANDFILL TIME DAY BEFORE, <br /> Rev 11/09 NS-024 TRANSPORTER COPY - MANIFEST# ; <br /> I - <br />