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LJ Keller Canyon ❑Coffin Butte ❑Ox Mountain ❑Newby Island Forward <br /> Sanitary Landfill Landfill Sanitary Landfill Sar�'ry Landfill Landfill <br /> 901 Bailey Road 28972 Coffin Bu Road 12310 San Mateo Road 1601 t Z Landing Road 9999 S.Austin Road F <br /> Pittsburg, CA 94565 Corvallis, OR 97330 Half Moon Bay,CA 94019 Miipitas, CA 95035 Manteca, CA 95336 I <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)72&-9183 Fax(408)262-2871 Fax(209) 982-1009 <br /> NON-HAZARDOUS WASTE MANIFEST <br /> GENERATOR <br /> WASTE ACCEPTANCE N0, r <br /> MAILING ADDR $�g <br /> CITY, STATE, REQUIRED PERSONAL PROT TIV UIPMENT <br /> " LOVESO GOGGLES ❑RESPIRATOR s�ef ARD HAT <br /> PHONE 1 <br /> --° U TY VEKAFETY VEST <br /> CONTACT PERSON <br /> SPECIAL YHANLING PROCEDURES:SIGNATURE OF AUT IZ DAGENT/TIT1E DATE <br /> GENERATOR'S CERTIFICATION:I hereby certifythat the above med materia#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 a7cording 10 applicable <br /> regulations;AND,If the waste Is a treatment residue of a prevlousty restricted hazardous waste <br /> il 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 CFA Part 268 and.is no longer.a hazardous waste as defined by _ <br /> 40 CFR Part 261. _ <br /> WASTE E: i <br /> -- - - <br /> ❑CONSTRUCTION Q WOOD . <br /> O DEBRIS Li OTHER <br /> U SPECIAL WASTE <br /> GENERATING FACILITY <br /> TRANSPORTER _ NOTES: VEHICLE LICENSE NUMBER TRUCK NUMBER <br /> ADDRESS . � <br /> CITY,STATE,ZIP <br /> •Q <br /> PHONE --END -- - BOTTOM DUMP TRANSFER <br /> Lj <br /> SIGNATURE,OF AUTHORIZED AGENT OFt DRIVER DATE , R L-OFF(S) FLAT-BED VAN DRUMS <br /> Lk Ij <br /> 5= <br /> �.. � <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 DISosaL°METHOD: (TO BE COMPLETED BY LANDFILL) <br /> a is true and accurate. <br /> ~' DISPOSE OTHER <br /> P" <br /> ' REM •MICS ❑ SOIL <br /> O CONSTRUCTION <br /> h FACILITY 1ICKET N 'MBEREBRIS <br /> ❑NON- FRIABLE,. <br /> j t SBESTOSt-' ,. <br /> SIGNATURP OF))UTHORIZBD AGENT 64rv, 1 E - <br /> 4 17+OOD 4 tib` <br /> ❑ ASH <br /> r f 0 SPECIAL OTHER <br /> SCHEDULING MUST BE MAl�PRIORTO3:00 P.M.THE DAY PRIORTO EXPECTED ARRIVAL-ANY UNSCHEDULED LOADSARE SUBJECT <br /> TO REFUSAL UPON AFRI L. ONGaNG DAILY DELIVERIES MUST BE SCHEDULED WITH THE LANDFILL THE DAY�IBEFOR9. <br /> MANIFEST# �r9 8 <br />