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1D Keller Canyon ❑Coffin:Butte r Ox Mountain ❑Newby Island Forward <br /> r� , <br /> Sanitary Landfill La1dfilt Sanitary Landfill Sar"_ wry Landfill Landfil - <br /> 901 Bailey Road 28972 Coffin 136, Road 12310 San Mateo Road 1601 on Landing Road ' 9999:S, stip}�cad <br /> Pittsburg, CA 94565 Corvallis, OR 97330 Half Mooii,Bay;,CA 94019 Milpitas, CA 95035 Manteca, CW 36 s <br /> Phone (925)458-9800 -Phone (541)745-2018 --Phone(650) 726-1819 Phone (408) 945-2800 "Phone (2 )-98 4298 I <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 WASTE ACCEPTANCE NO. <br /> MAILING ADDRESS MAILING ADDRESS <br /> s do Hol e 9905 <br /> CITY, STATE,ZIP REQUIRED PERSONAL PROTECTIVE EQUIPMENT I <br /> Tracv.CA-05304 C GLOVES 0 GOGGLES El RESPIRATOR 31 HARD HAT. <br /> PHONE <br /> ❑TY-VEK LIMAFETY VEST <br /> (209)83A-70;70 <br /> d <br /> CONTACT PERSON SPECIAL HANDLING PROCEDURES: <br /> SIGNATURE OF.AUTHORIZED AGENT/TITLE DATE k <br /> Ar <br /> GENERATOR'S CERTIFICATION:I hereby certify that the above named material is not a hazardous . k <br /> waste as defined by 40 CFR Part 261 or title 22 of the Califomfa code of regulations,has been property <br /> described,classified and packaged;and is in proper condition for transportation according to applicable - <br /> feguiatiors;AND,if the waste is a treatment residue of a previously restricted haiardous waste _ <br /> subject to the land Disposal Restrictions,1 certify and warrant that the waste has been treated in RECEIVING FACILITY F <br /> _accordance with the requirements of-4 FR,P.art.268 and.is:rlo-longer a hazardous waste as defined by <br /> .40 CFR Part 2PA. "- <br /> WAST P.E { .' <br /> ❑SLUDGE <br /> -<❑CONSTRUCTION' ❑WOOD - <br /> 1 . " O DEBRIS ❑OTHER <br /> ❑SPECIAL WASTE <br /> GENERATING FACILITY. <br /> _.... <br /> TRANSPORTER1' •...: •_ <br /> NOTES: VEHICLE LICENSE NUMBER `"TRUCK NUMBER <br /> ADDRESS .- <br /> CITY, STATE, ZIP } E. <br /> Lod!LCA 95 <br /> _ <br /> -PHONE-__ BOTTOM DUMP. ____TRANSFER' ' = <br /> SIGNATURE OF AUTHORIZED AGENT OR DRIVER. DATE ROLL-OFFS FLAT-BED VAN `;. . DRUMS ,'• ... ' <br /> ❑ ❑ ❑ ❑ <br /> f .• <br /> CUBIC YARDS r <br /> hereby certify that the above named material has been <br /> accepted and to the best Of my knowledge the foregoing DISPOSAL METHOD: (Tfl BE COMPLETED-BY LANDFILL) <br /> is true and accurate. 7. <br /> DISPOSE OTHER <br /> ❑ SOIL <br /> REMARKS--,,, ❑ CONSTRUCTION <br /> f' DEBRIS <br /> FACIkeITY TICKET NUMBF - ❑ NON-FRIABE <br /> � . ASB STOS <br /> SIGNATURE -.F AUTH®RIZED'AG q NT .r' ( D fE. <br /> / LWO D' <br /> x AS ' <br /> t O SPECIAL OTHER <br /> i SCHEDULING MUST BE MADE PRl R TO 3:00 P.M.THE.DAY PRIOR TO EXPECTED ARRIVAL•ANY UNSCHEDULED LOADS ARE SUBJECT ' <br /> TO REFUSAL UPON ARRIVAL.ANGOING DAILY DELIVERIES MUST DE SCHEDULED WITH THE LANDFILL THE DAY BEFORE. <br /> €MANIFEST#� <br /> :Rev-11/09 NS-024Y TRANSPORTER-COPY <br />