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U Keller Canyon ❑ Coffin Butte ❑Ox Mountain ❑ Newby Island ]Forward <br /> Sanitary Landfill Landfll�,. Sanitary Landfill C�tary Landfill Landfill <br /> 901 Bailey Road 28972 Coffin ifte Road 12310 San Mateo Road 1601 Dixon Landing Road 9999 S.Austin Road <br /> Pittsburg, CA 94565 Corvallis, ¢R-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)745-3828t Fax(650)726-9183 Fax(408)262-2871 Fax(209)982-1009 <br /> • <br /> NON-HAZARDOUS WASTE MANIFEST <br /> GENERATOR ! V <br /> MAILING DRESS WASTE ACCEPTANCE NO. <br /> - <br /> CITY SATE, Zip `' REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> P E <br /> ❑GLOVES ❑GOGGLES ©RESPIRATOR HARD HAT <br /> f C7 TY VEK ❑ SAFETY VEST <br /> CONT TP RSON <br /> SPECIAL HANDLING PROCEDURES: <br /> SIGNATURE 1DF AUTHORIZED AGENT/TITLE DATE <br /> * r10 <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 a-cording to applicable - <br /> regulatiow ANO,If the waste is a treatment realdus 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 /> _n DlqPQSAl ,. <br /> L <br /> OCONSTRUCTION C3 WOOD f — -- r --- <br /> ❑DEBRIStis <br /> OTHER t ate#^ <br /> ❑SPECIAL WASTE <br /> GENERATING FACILITY <br /> TRAIS yS'ORTE6 NOTES: VEHICLE LICENSE NUMBER TRUCK..'Nu " R I <br /> ADD S$ ,.." <br /> f s <br /> % $ # <br /> CITY, STATE,ZIP <br /> — PHONE a• s ,e--, END DUMP BOTTOM DUMP TRANSFER <br /> ❑ <br /> SIGNATURE OF AUTHORIZED AGENT OR DRIVER DATE ROLL-OFF(S) FLAT-BED VAN DRUMS <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 DISPOSAL METHOD: (TO BE COMPLETED BY LANDFILL) <br /> is true and accurate. <br /> ` DISPOSE OTHER <br /> FIEMARKS 0 SOIL <br /> _ ❑'CONSTRUG�TION <br /> FACILITY TICKLT NUMBER DEBRIS �; <br /> I/ ❑ NON-FRIABLE <br /> SIGNATURE OFAUT+JORIZEDAG • T DATE ASBESTOS , <br /> ❑WO <br /> PD <br /> ,- <br /> �. r ❑ C AI L O HER <br /> SCHEDULING MUST BE MADE P IORTO 3:00 P.M.THE DAY PRIORTO EXPECTED ARRIVAL*ANY UNSCHEDULED LOADS ARE SUBJECT <br /> TO REFUSAL UPON ARRIVA . ONGOING DAILY DELIVERIES MUST BE SCHEDULED WITH THE LANDFILL THE DAY BEFORE. <br /> MANIFEST# a ?7 a Q <br />