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❑Keller Canyon ❑Coffin Butte ❑Ox Mountain ❑Newby Island ?Forward <br /> Sanitary Landfill Landfill Sanitary.Landfill Sa"" ,ry Landfill . Landfill <br /> 901 Bailey Road 28972 Coffin B Road 12310 San Mateo Road 160 on Landing Road 9999 S. Austin Road <br /> Pittsburg, CA 94565 Corvallis, OR 97330 Half Moon Bay, CA 94019 Milpitas, CA 95035 Manteca, CA 05336 <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 /> i <br /> GENERATOR WASTE ACCEPTANCE NO. k <br /> MAILING ADD ESS <br /> 20500 Soulh Ho 9905 Drive — h <br /> CITY, STATE, ZIP. REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> TMWY,CA95304 PHONE MGLOVES ❑ GOGGLES ❑ RESPIRATOR 3] HARD HAT <br /> � _ <br /> ❑TY-VEK [XSAFETY VEST <br /> CON ACT`:R5FiSON <br /> Azme SPECIAL HANDLING PROCEDURES: j <br /> SIGNATURE OF AUTHORIZED AGENT/TITLE DATE <br /> d <br /> GENERATOR'S CERTIFICATION:I hereby certify that the above namedaterial 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 f <br /> described,classified arid packaged,and Is in proper condition for transportation according to applicable _ <br /> regulations;AND,It the waste is a treatment residue 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,reguirements of 90 jCER Part 266 and is no longer a hazardous waste as defined by <br /> 40 CFR Part 261. - <br /> WASTE TYPE: . ,y + <br /> ISPOSAL ❑SLUDGE <br /> ❑CONSTRUCTION ID WOOD <br /> ❑DEBRIS Q OTHER <br /> ❑SPECIAL WASTE <br /> GENERATING FACILITY <br /> 2€5M SvU&Holly Drive ICY" <br /> TRANSPORTER NOTES: VEHICLE LICENSE NU—MBER1 TRUCK NUMBER <br /> ADDRESS <br /> Rod Offig@ Box 357 <br /> • r <br /> CITY, STATE, ZIP <br /> .�. <br /> -PHONE , �. � .- _. —.END DUMP _ BOTfOM_bUMP TRANSFER <br /> - ❑ <br /> SIGNATURE OF AUTHORIZED AGENT OR DRIVER DATE R F(S) FLAT-BED VAN DRUMS y <br /> I <br /> CUBIC YARDS <br /> I hereby certify that the ab_ 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 /> REMARKS <br /> O CONSTRUCTION <br /> FACILITY TICKET NUMBER DEBRIS <br /> ❑ NON-FRIABLE <br /> tI A RESTOS <br /> SIGNATURE OF THORIZE AGENT <br /> 'Q OD <br /> 0 ASH <br /> ~ � ❑ SPECIAL OTHER <br /> SCHEDULING MUST BE MADE PRIO O 3:00 P.M.THE DAY PRIOR TO EXPECTED ARRIVAL•ANY UNSCHEDULED LOADS ARE SUBJECT <br /> TO REFUSAL UPON ARRIVAL. O GOING DAILY DELIVERIES MUST BE SCHEDULED WITH THE LANDFILL THi6AY BEFORE. f <br /> MANIFEST <br /> Rev 11109 NS-024 GENERATOR,COPY - # ,� , <br />