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❑Keller Canyon ❑Coffin Butte ❑Ox Mountain ❑ Newby IslandForward <br /> Sanitary Landfill Landfill Sanitary Landfill Sani� * Landfill Landfill <br /> 901 Bailey Road 28972 Coffin B W ad 12310 San Mateo Road 1601 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 /> NON-HAZARDOUS WASTE MANIFEST <br /> GENERATOR <br /> WASTE ACCEPTANCE NO. <br /> L° MAILING DRESS <br /> CITY S•ATE,ZIP A IREQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> } ❑GLOVES Q GOGGLES ❑RESPIRATOR1HARD HAT,= _ , <br /> P E q..�... <br /> a TY-VEK ❑ SAFETY VEST <br /> CONTAMT T P RSON' <br /> f- SR_ C.IAL HANDLING PROCEDURES: <br /> SIGN E OF AUTHORIZED AGENT/TITLE DATE <br /> F � <br /> * r` -= E <br /> GENERATOR'S CERTIFICATION:I hereby ceitify that the above named material is not a hazardous <br /> waste as defined by 40 CFR Part 261 or title 22 of the Cafifornia code of regulations,bas been property - <br /> - described,classified and packaged,and is in proper condition e <br /> for transportation acccrding to applicable, <br /> - <br /> regulations;AND,if the waste is a treatment resldut of a previously restricted hazardous waste <br /> �<•� subject to the Land Gispaal Restrictions,I certify antl 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 Paa 261. <br /> WASTE TYPE: <br /> - <br /> 0 CONSTRUCTION ❑WOOD <br /> O DEBRIS C OTHER <br /> ❑SPECIAL WASTE`.. <br /> " ) GENERATING FACILITY " <br /> TRANSPOR ` NOTES: VEHICLE LICENSE NUMBER TRUCK NUMBER <br /> - � <br /> ADD SS <br /> .24 <br /> CITY, STATE,ZIP <br /> PHONE --END-DUMP- - BOTTOM DUMP TRANSFER <br /> ❑ g ❑ .. <br /> SIGNATURE OF AUTHORIZED AGENT OR DRIVER DATE ROLL-OFF(S) FLAT-BED VAN DRUMS <br /> ❑ ❑ ❑ ❑ <br /> zr <br /> r` 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 /> ❑ SOIL <br /> FiEMAR <br /> 1 0 CONSTRUCTION <br /> DEBRIS <br /> FAC19ITY TICKET NUMBER ❑ NON-FRIABLE <br /> r ASBESTOS <br /> SI ATUREIOF AUT,HORIZE,D AGENT DATE <br /> f < Q OPD <br /> q H I I <br /> ! / f ❑ S CIALL OTil ER <br /> SCHEDULING MUST BE MADEORTO 3:00 P M.THE DAY PIRIORTO EXPECTED ARRIVAL•ANY UNSCHEDULED LOADS ARE SUBJECT <br /> TO REFUSAL UPON ARRIVA . ONGOING DAILY DELIVERIES MUST BE SCHEDULED WITH-THE .LANDFILL THE DAIS BEFORE. <br /> MANIFEST" 97738' <br /> l738 <br /> r_cnic�n�no�+�,nv <br />