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T1 Keller Canyon ❑C off ❑Ox Mountain " . ❑Newby Island 7 Forward <br /> Sanitary. Landfill Landfill - -Sanitary Landfill �" }'tary Landfill Landfill <br /> �g' u'er <br /> 901 Bailey Road "` 28972 Coffin utte Lioad 12310 San Mateo Road 1 Dixon LandingRoad 9999 S,/Xus rf oad <br /> Pittsburg,CA 94565 Corvallis,OR 97330 , . Haff Moon Bay, CA 94019 Milpitas' CA 95035 Manteca;'CA 95 3fi <br /> Phone (925)458 9800 Phone (541) 745-2018 Phone(650)726-1819 Phone (408) 945 280D Phone (209) 98 -4298 <br /> Fax(925)458-9891 Fax (541;)745-3826 . Fax (650)726-9183 Fax(408) 262-2871 Fax (209j`9 1009 <br /> NON-HAZARDOUS WASTE MANIFEST. i <br /> . 3 w <br /> GENERATOR WASTE ACCEPTANCE NO. <br /> - - <br /> AILING ADDRESS <br /> 2050D Soaks geft Drive <br /> CITY, STATE,ZIP REQUIREDPERSONAL PROTECTIVE EQUIPMENT <br /> 'Fmcv.CA 03304 GLOVES U GOGGLES ❑ RESPIRATOR YQ HARD HAT <br /> PHONE <br /> (2M-834-'1679 ❑TY-VEK [XSAFETY VEST <br /> CONTACT PERSON <br /> SPECIAL HANDLING PROCEDURES: <br /> Anne Qpv�L <br /> SIGNATURE OF AUTHORIZED AGENT/TITLE DATE , <br /> GENERATOR'S CERTIFICATION:I hereby certify that the above na ed 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 apreviously restricted hazardous waste <br /> subject to the Land Disposal Restrictions,l certify and warrant that the waste has been treated in RECEIVING FACILITY <br /> - ,-accordance with the-reg6irements of 40,CFR.Part 268.and-is no longer a haaardous waste as defined by - I <br /> 40 CFR Part 261. , '.r'"v`• - - _ - - _ ' <br /> WASTE.7YPE <br /> _❑-SL.U.��. <br /> O CONSTRUCTION ❑WOOD <br /> ❑DEBRIS ❑OTHER <br /> ❑SPECIAL:WASTE <br /> GENERATING FACILITY` I <br /> 2"XI0 tow He Ike TRACE <br /> TRANSPORTER NOTES: VEHICLE LICENSE NUMBER TRUCK NUMBER <br /> ADDRESS <br /> CITY,STATE,•ZIPT-04-CA#5241 31 <br /> f <br /> t R <br /> PHONE--- <br /> BOTTOM-DUMP. TRANSFER . <br /> SIGNATURE OF AUTHORIZED AGENT.OR DRIVER DATE R.Q. - PES FLAT BED VAN DRUMS <br /> Ell ❑ [jr <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 6Y LANDFILL) <br /> is true and accurate, <br /> DISPOSE OTHER <br /> ❑ SOIL <br /> REMARKS <br /> ❑ CONSTRUCTION <br /> FACILITY TICKET,NUMBER DEBRIS_ <br /> ❑ NON-FRIABLE <br /> ASBESTOS <br /> SIGNATURE OF AUTHORIZED AGE DATE . <br /> ❑ WOOD <br /> ❑ ASH <br /> Ll SPECIAL OTHER <br /> SCHEDULING MUST BE MADE PRIOTO o P.M-THE DAY PRIOR TO EXPECTED ARRIVAL o ANY UNSCHEDULED LOADS ARE:SUBJECT j <br /> - TO REFUSAL UPON ARRIVAL.O I DAILY DELIVERIES MUST BE SCHEDULED WITH THE LANDFILL THE DAY BEFORE. <br /> MANIFEST# <br /> Rev 11/09 NS-024 TRANSPORTER COPY ,, e, <br />