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r _ <br /> ❑ Keller Canyon ❑ Ox Mountain ❑ Newby Island !R,❑ 1=onward <br /> Sapitary,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)982-42 <br /> Fax (925)458-9891 Fax(650) 726-9183 Fax (408) 262-2871 Fax(209) 982-1� <br /> NON-HAZARDOUS WASTE MANIFEST <br /> GENERATOR WASTE ACCEPTANCE NO. <br /> MAILING ADDRESS <br /> CITY, STATE,—ZIP REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> PHONE a GLOVES Q GOGGLES ❑RESPIRATOR U HARD HAT <br /> CONTACT PERSON <br /> 0 TY-VEK O OTHER <br /> �r, 1 , f �- t „�, , ,� <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 Ltls 22 of the California code of regulations has been properly <br /> described dasslfled and packaged and is in proper condition for tranaperiahon a-cording to applicable <br /> regulations AND,If the wasto lea treatment residue of a Proviouely mstrlcted hsrardous waste <br /> subject to the Land Disposal Restrictions t certify And warrant That the waste has been treated in RECEIVING FACILITY <br /> accordance!with the requirements of 40 CFR Part 266 and is no longer a hazardous waste as defined by <br /> 40 CFR Part 261 <br /> WASTE TYPE <br /> D DISPOSAL ❑SLUDGE <br /> Q CONSTRUCTION `ID WOOD 1 <br /> O DEBRIS .Q OTHER <br /> ❑SPECIAL WASTE <br /> GENERATING FACILITY <br /> TRANSPORTER .r — _ NOTES VEHICLE LICENSE NUMBER TRUCK NUMBER <br /> ADDRESS t _ t� T`' f' •�f�I ! - a <br /> CITY, STATE, ZIP,-- �- i _ -- -- — <br /> — - <br /> PHONE / w f -- — —END DUMP BOTTOM DUMP TRANSFER <br /> SIGNATURE OF AUTHORIZED AGENT OR DRIVER MDATE ROLL-OFFS FLAT-BED VAN 'MUMS <br /> U U U U <br /> * f' r` f/ �e _ `� t <br /> CUBIC YARDS ' <br /> 1 hereby certify that the above named material has been <br /> - accepted and to the best of my knowledge the foregoing <br /> Is true and accurate DISPOSAL METHOD (TO BE COMPLETED BY LANDFILL) <br /> DISPOSE OTHER <br /> REMARKS 0 SOIL <br /> �. Q CONSTRUG7ION <br /> FACILITY TICKET NUMBER DEBRIS <br /> €til f I Q NON-FRIABLE <br /> SIGNATURe-OF RUTH [ZED AGENT DATE ASBESTOS <br /> Q WOOD <br /> 1 L� <br /> ! <br /> la O ASH <br /> ❑SPECIAL OTHER <br /> SCHEDUUNG MUST ISE MAGE PRIORT0 3.00 PM.THE DAY PRIOR TO EXPECTED ARRIVAL a ANY UNSCHEDULED LOADS ARE SUBJECT <br /> "r'O REFUSAL UPON ARRIVAL ONGOING DAILY DELIVERIES MUST BE SCHEDULED WITH THE LANDFILL THE DAY BEFORE <br /> MANIFEST& A -4 A Q A <br />