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' ❑ Keller Canyon ❑ Ox Mountain ❑ Newby Island ❑ Forward <br /> Sanitary Landfill Sanitary Landfill Sanitary Landfill Landfill <br /> 901 Bailey Road 12310 San Mateo Road 1601 Dixon Landing Road 9999 S Austin Road <br />' Pittsburg,CA 94565 Half Moon Bay, CA 94019 Milpitas,CA 95035 Manteca,CA 95336 <br /> Phone(925)458-9800 Phone(650)726-1819 Phone(408) 945-2800 Phone(209) 982-4298 <br /> Fax(925)458-9891 Fax(650)726-9183 Fax(408)262-2871 Fax(209) 982-1009 <br />' <br /> GENERATOR NON-HAZARDOUS WASTE MANIFEST <br /> WASTE ACCEPTANCE NO. <br /> MAILING ADDRESS 128 <br /> CITY,STATE,ZIP REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> I:A95202 U GLOVES a GOGGLES O RESPIRATOR ❑HARD HAT <br />' PHONE <br /> (209)937-074 D TY VEK t7 OTHER <br /> CONTACT PERSON SPECIAL HANDLING PROCEDURES <br /> SLlrtla <br />' SIGNATURE OF AUTHORIZED AGENT/TITLE DATE <br /> *NOV <br /> GENERATOR 8 CERTIFICATION.I hereby rtdy that the above named mateAal is not a hazardous <br /> waste as defined by 40 CFR Part 267 or tltle 22 of the CalifomW eode of regulations,has been properly <br /> described,olassirwd and packaged and Is In proper condition for transportation avording to appkkable <br /> regalatkms,AND,It the waste Is a traelment residue of a previously resbioted hazardous waste <br /> sued to the Land Disposal Rastrletbons I certify and warrant that the waste hag been treated In RECEIVING FACILITY <br />' accordance with the regwroments of 40 CFR Pari 268 and Is no longer a hazardous waste as defined by <br /> 40 CFR Part 261 <br /> WASTE TYPE <br /> ❑DISPOSAL O SLUDGE <br /> •CONSTRUCTION Q WOOD <br /> •DEBRIS O OTHER <br /> ❑SPECIAL WASTE <br /> GENERATING FACILITY <br /> 110 Wed Seneca St. ST CKXrON <br /> TRANSPORTER NOTES VEHICLE LICENSE;NUMBED TRUCK NUMBER <br /> pLOT Oil ca. 6' AADDRESS <br /> 351 Nm&Bedbum Rd <br /> CITY,STATE,ZIP <br /> 1t�CA 95240 <br /> PHONE END DUMP BOTTOM DUMP TRANSFER <br /> 175 01 ❑ - ❑ <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 /> REMARKS ❑ SOIL <br /> CONSTRUCTION <br /> FACILITY TICKET NUMBER DEBRIS <br /> pNON-FRIABLE <br /> lei I'll / ASBESTOS <br /> SIGNATURE OF AUTHORIZED AGENT D <br /> ❑wooD <br /> I ❑ASH <br /> O SPECIAL OTHER <br /> 1 <br /> SCHEDULING MUST BE MADE PRIORTO 3:00 P.M.THE DAY PRIORTO EXPECTED ARRIVAL a ANY UNSCHEDULED LOADS ARE SUBJECT <br /> TO REFUSAL UPON ARRIVAL. ONGOING DAILY DELIVERIES MUST BE SCHEDULED WITH THE LANDFILL THE DAY BEFORE. <br /> ,.,..„, MANIFEST# 1 A 7 7 9 S <br />