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LJKeller Canyon ❑Coffin Butte ❑Ox Mountain ---Ph'6AyAsland ] Forward <br /> Sanitary Landfill Landfill Sanitary Landfill Sal' ry Landfill Landfill <br /> 901 Bailey Road 28972 Coffin BV'Road 12310 San Mateo Road 1601 Dixon Landing Road 9993 S.Austin Load <br /> Pittsburg, CA 94565 Corvallis,OR 97330 Half Moon Bay, CA 94019 Milpitas, CA 95035 Manteca, CA 95336/ G <br /> Phone (925) 458-9800 Phone (541) 745-2018 Phone (650) 726-1819 Phone (408) 945-2800 Phone(209).982­4298 t <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. <br /> MAILING ADD ESS - � ���� , <br /> 20500 South Ho Drive � <br /> CITY, STATE, ZIP REQUIRED PERSONA]_ PROTECTIVE EQUIPMENT t <br /> PHONE iXGLOVES ❑ GOGGLES ❑ RESPIRATOR 3] HARD HAT <br /> ❑ TY-VEK IXSAFETY VEST <br /> CON ACT PERSON <br /> A 'E SPECIAL HANDLING PROCEDURES: <br /> SIGNATURE OF AUTHORIZED AGENT/TITLE DATE <br /> i I <br /> GENERATOR'S CERTIFICATION:I hereby certify that the above named m terial is not a hazardous <br /> wasteas 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 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 40 GFR Part'268 and is no longer a-hazardeus waste as defined by - ; <br /> 40 CFR Part261. - <br /> WASTE TYPE: <br /> SPOSAL ❑SLUDGE <br /> ❑CONSTRUCTION ❑WOOD <br /> ❑DEBRIS ❑OTHER <br /> ❑SPECIAL WASTE <br /> GENERATING FACILITY <br /> 20500 Soutb Horsy Drive TRACY <br /> TRANSPORTER NOTES: VEHICLE LICENSE NUMBER TRUCK NUMBER <br /> r—lborpe Oil E3C <br /> ADDRESS t <br /> - lp 357 <br /> CITY, ST , Z <br /> tadi.CA 95241 <br /> PHONE ,___ __. ._` ------_ FIND DLfMP� B07TOM_DU_MP----- TRANSFER <br /> ❑ ❑ - <br /> SIGNATURE OF AUTHORIZED AGENT OR DRIVER DATE ROLL-OFFS FLAT-BED VAN DRUMS <br /> ❑ ❑ ❑ ❑ <br /> i <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 <br /> i5 true and accurate. DISPOSAL METHOD: (TO 13E COMPLETED BY LANDFILL) <br /> ti <br /> DISPOSE OTHER <br /> REMARKS ❑ SOIL <br /> ❑ CONSTRUCTION <br /> FACILITY Tl KET NUMBER DEBRIS <br /> ❑ NON-FR t BLE` I <br /> ASBEST S <br /> SIGNATU OF AOTHORIZECYAGENT N DA E <br /> E OD <br /> �H <br /> ' PECIAL OTHE <br /> i <br /> SCHEDULING MUST BE MADE PRIOR TO'3: 0 P.M.THE DAY PR16R TO EXPECTED ARRIVAL-ANY UNSCHEDULED LOADS ARE SUBJECT' <br /> TO-REFUSAL UPON ARRIVAL.ONGOI G DAILY DELIVERIES MUST BE SCHEDULED WITH THE LANDFILL THE DAY BEFORE, <br /> Rev 169�_NS-024 . GENERATOR COPY MANIFEST# -6-1.5114 ' <br />