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'❑ Keller Canyon ❑ Ox-Mountain ❑ Newby Island '21-Forward <br /> Sanitary tandfirl 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 Say, 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 /> NDN-HAZARDOUS WASTE MANIFEST <br /> NiWGENERATOR � , �. , <br /> WASTE ACCEPTANCE NO. <br /> '�_4 /��,��,''r.- <br /> CITY, STATE,ZIP REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> PHONE U GLOVES ❑GOGGLES U RESPIRATOR ❑HARD HAT <br /> D TY-VEK U OTHER <br /> CONTACT PERSON / , SPECIAL HANDLING PROCEDURES <br /> SIGNATURE OF AUTHORIZED AGENT!TITLE DATE <br /> GENERATOR S CERTIFICATION I hereby certify that the above narned material is not a hazardous <br /> waste as defined by 40 CFR Part 261 or title 22 of the California coda of regulations has been properly <br /> desenbed dassiGad and packaged and is in proper condition for transportation a^carding to appiicablo <br /> regulations AND it the waste In 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 regwrements oe 40 GFR Part 268 and Is no longer a hazardous waste as defined by <br /> 40 CFR Part 261 <br /> WASTE TYPE <br /> U DISPOSAL ❑SLUDGE <br /> ❑CONSTRUCTION Q UOOD <br /> ❑DEBRIS >�OTHER <br /> ❑SPECIAL WASTE <br /> GENERATING FACILITY <br /> � / l <br /> 77 F <br /> , - <br /> TRANSPORTER '.r , �, NOTES VEHICLE LICENSE NUMBER TRUCK NUMBER <br /> ADDRESS <br /> 11MZ a <br /> <r j < <br /> CITY,STATE,DP 7;7 <br /> PHONE END DUMP BOTTOM DUMP TRANSFER <br /> SIGNATURE OF AUTHORIZED AGENT OR DRIVER DATE ROLLOFF S FLAT-BED VAN DRUMS <br /> f <br /> Q ❑ ❑ <br /> s _ <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 /> Is true and accurateDISPOSAL METHOD (TO BE COMPLETED BY LANDFILL) <br /> DISPOSE OTHER <br /> SUREMARK <br /> O SOIL <br /> ❑CONSTRUCTION <br /> FACILITY TICKET NUMBER DEBRIS <br /> C1 NON-FRIABLE <br /> ASBESTOS <br /> SIGNATURE OF AUTHORIZED AGENT DATE <br /> C]WOOD <br /> _f <br /> I ❑ASH <br /> C3AL OTHER <br /> HEDULING MUST BE MADE PRIORT0 3 00 P M THE DAY PPRIORTO EXPECTED A AL 9 ANY UNSCHEDULED LOADS ARE SUBJECT <br /> 1O REFUSAL UPON ARRIVAL ONGOING DAILY DELIVERIES MUST RE A OULED WITH THE LANDFILL THE DAY BEFORE <br /> MANIFFRT 4 A Q W7 9 <br />