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t] 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 /> Pittsourg,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) 982-10 <br /> NON-HAZARDOUS WASTE MANIFEST <br /> GENERATORcT4t t" ' _r"` '-i <br /> WASTE ACCEPTANCE NO. <br /> MAILINGADDRESS <br /> CITY, STATE,ZIP ; x c ��`-� ,I• REQUIRED PERSONAL PROTECTIVE EQEHARD <br /> ❑GLOVES ❑GOGGLES O RESPIRATOR AT <br /> PHONE <br /> Li TY-VEK a OTHER <br /> CONTACT PERSON : t'�' t _t a i` ` k_'-� i �,! <br /> SPECIAL'HANDLING PROCEDURES <br /> SIGNATURE OF AUTHORIZED AGENT/TITLE DATE <br /> GENERATOR S CERTIFICATION I hereby certify that the above named material is not a hazardous <br /> waste as defined by 40 CFR Part 261 or title 22 of the California code of reputations has been properly <br /> described dassdied and packaged and,s,n proper condition for transportation a-cording 10 applicable <br /> regulations AND,If the waste Is a treatment residue of a previously restricted hazardous waste <br /> subject to the Land Disposal Rosoctions I certify and warrant that the waste has been treated to RECEIVING FACILITY <br /> accordance with the regwTements of 40 CFR Part 268 and,s no longer a hazardous waste as defined by <br /> 40 CFR Part 261 <br /> WASTE TYPE <br /> •DISPOSAL a SLUDGE <br /> O CONSTRUCTION U WOOD 3 <br /> ❑DEBRIS "OTHER <br /> 0 SPECIAL WASTE <br /> GENERATING FACILITYZMENINIZE <br /> - <br /> TRANSPORTER ; 4�E y ti tc` y" NOTES VEHICLE LICENSE NUMBER TRUCK NUMBER <br /> ADDRESS t ' , # <br /> CITY, STATE,ZIP <br /> PHONE END DUMP BOTTOM DUMP TRANSFER <br /> SIGNATURE OF AUTHORIZED AGENT OR DRIVER DATE ROLL-OFFS FLAT-BED VAN RUMS <br /> ❑ Q Q Q <br /> ¢¢ r tI <br /> CUBIC YARDS <br /> I hereby certify that the abode named material has been <br /> accepted and to the best of my knowledge he foregoing DISPOSAL METHOD (TO BE COMPLETEDBY LANDFILL) <br /> Is true and accurate. <br /> DISPOSE OTHER <br /> ❑SOIL <br /> REMARKS 1 <br /> D CONSTRUCTION <br /> DEBRIS <br /> FACILITY TICKET NUMBER r5 O NON-FRIABLE <br /> ASBESTOS <br /> SIGNATURE OF AUTHORIZED AGENT , DATE <br /> T D WOOD <br /> ❑ ASH _LLLL <br /> SPECIAL OTHER <br /> SCHEDULING MAST BE MADE PRIOR TO 3 OOP M THE DAY PRIORTO EXPECTED ARRIVAL*ANY UNSCHEDULED LORDS ARE SUBJEC <br /> TO REFUSAL UPON ARRIVAL ONGOING DAILY DELIVERIES MUST BE SCHEDULED WITH THE LANDFILL THE DAY BEFORE. <br /> MANIFEST# - 43683 <br />