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{FK j'4�'y^s��+^�"�"�e n 4S"�"s,�%�' h��`�� aT�`K' - -e a i3"�-sT cax�s��'�a x 'inn"s i ^.F � r t�� �,{ - t�, y 1 <br /> ` ;l elier�Ca on:�- '�, ❑ K oluntain �, ;, _ "' , ,p�SNewby�IsiandY :Y, F+arwardr <br /> fianitahkILandfili Sanitai�yj L'andfIll` Sanitary,Landfill Landfill <br /> 901 Galley 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 /> Phorke`(925) 458-9804 Phone(650) 726-1819 Phone(408)945-2800 Phone(209) 982-429f�, <br /> Fax (925)458-9891 Fax(650),726-9183 Fax (408)262-2871 Fax(209)982-1009 <br /> NON-HAZARDOUS WASTE MANIFEST <br /> GENERATO <br /> WASTE ACCEPTANCE NO. <br /> MAILING ADDRESS _ <br /> t <br /> CITY, STATE,ZIP REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> 1 CI GLOVES Q GOGGLES U RESPIRATOR Q HARD HAT <br /> PHONE <br /> Q TY VEK O OTHER <br /> CONTACT PERSONSPECIAL HANDLING PROCEDURES <br /> 11/11 O - - <br /> SIGNATURE OF AUTHORIZED AGENT/TITLE DATE <br /> * � l <br /> GENERATORS CERTIFICATION I hereby certdy that the above named material is not a hazardous <br /> waste as defined by 40 CFR Part 261 or title 22 of the Caldomia code of regulations has been properly <br /> described classified and packaged and is to proper condition for transportation a-cording to applicable <br /> regulations ANN It the waste is a treatment residue of a previously restricted hazardous waste <br /> subject to the land Disposal Restnctions i certity and warrant that the waste has been treated in RECEIVING FACILITY <br /> accordance with the reclusrements of 40 CFR Part 266 and is no longer a hazardous waste as defined by <br /> 40 CFR Part 261 <br /> WASTE TYPE <br /> •DISPOSAL Q SLUDGE <br /> ❑CONSTRUCTION O WOOD <br /> O DEBRIS OTHER - <br /> O SPECIAL WASTE r <br /> GENERATING FACILITY <br /> TRANSPORTER NOTES VEHICLE LICENSE NUMBER.:, TRUCK NUMB <br /> ADDRESS ✓� � � <br /> CITY, STATE,ZIP T—n v7 <br /> PHONE END DUMP BOTTOM DUMP TRANSFER`- <br /> - - - - - - - - -- - ❑ - - ❑ <br /> SIGNATURE OF AUTHORIZED AGENT OR DRIVER DATE ROLL-OFF(S) FLAT-BED VAN nF4LIMS <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 DISPOSAL METHOD (TO BE COMPLETED BY LANDFILL) <br /> Is true and accurate. <br /> DISPOSE OTHER <br /> �/ ❑ SOIL <br /> EMARKS <br /> Q CONSTRUCTION <br /> FACILITY TICKET NUMBER DEBRIS <br /> 0NON-fRIAf3LE <br /> ASBESTOS <br /> SIGNATURE OF AUTHORIZED AGENT DATE <br /> O WOOD <br /> ❑ASH <br /> ❑ SPECIAL OTHER <br /> SCHEDULING MUST BE MADE PRIORTO 3 00 RM THE DAY PRIORTO EXPECTED ARRIVAL a ANY UNSCHEDULED LOADS ARE SUBJE3 <br /> TO REFUSAL UPON ARRIVAL. ONGOING DAILY DELIVERIES MUST BE SCHEDULED WITH THE LANDFILL THE DAB EF <br /> ' MANIFEST#i 6 5 G <br />