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❑ Keller Canyon ❑ Ox Mountain ❑ Newby Island Ox Forward <br /> Sanitary Landfill Sanitary Landfill Sanitary Landfill Landfill <br /> 901 Bailey Road 12310 San Mateo Road 1641 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 /> NON-HAZARDOUS WASTE MANIFEST <br /> GENERATOR <br /> WASTE ACCEPTANCE N0. <br /> MAILING ADDRESS <br /> CITY, STATE, ZIP - REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> PHONE ❑GLOVES ❑GOGGLES ❑RESPIRATOR ❑HARD HAT <br /> f r, U TY-VEK D OTHER <br /> CONTACT PERSON r- L tom' SPECIAL HANDLING PROCEDURES <br />' SIGNATURE OF AUTHORIZED AGENT/TITLE DATE <br /> * �aa +rte <br /> GENERATOR S CERTIFICATION I hereby certAy that the above named malarial is not a hazardous <br /> waste as defined try 40 CFR Part 261 or title 22 of the Caliornia code of regulations has been properly <br /> described classified and packaged and Is in proper condition for transportation a`cording to applicable <br /> regulations AND,If the waste Is s treatment reefdue 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 requirements of 40 CFR Part 269 and is no longer a hazardous waste as defined by <br /> 40 CFR Part 261 <br /> WASTE TYPE <br /> ❑DISPOSAL ❑SLUDGE <br />' •CONSTRUCTION Q WOOD <br /> IJ DEBRIS 4 OTHER <br /> ❑SPECIAL WASTE <br /> GENERATING FACILITY <br /> v� <br /> L < yr l ^ <br /> k! itr�J k r'Z <br /> TRANSPORTER NOTES VEHICLE LICENSE NUMBER TRUCK NUMBER <br /> ® _ <br /> ADDRESS �r s �t�`: �' �'�'� ��, �- �- � 7 <br /> CITY, STATE, ZIP <br /> PHONE END DUMP BOTTOM DUMP TRANSFER <br /> SIGNATURE OF AUTHORIZED AGENT OR DRIVER DATE ROLL-OFF(S) FLAT-BED VAN DRUMS <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 /> EMARKS ❑ SOIL <br /> _ D CONSTRUCTION <br /> FACILITY TICKET NUMBER DEBRIS <br /> ❑ NON-FRIABLE <br /> ASBESTOS <br /> SIGNATURE OF AUTHORIZED AGENT DATE <br /> U WOOD <br /> r <br /> i] ASH <br /> Lk SPECIAL orHER <br /> CHEDULING MUST BE MI1 DE PRIOR TO 3 00 P M.THE DAY PRIORTO EXPECTED ARRIVAL a ANY UNSCHEDULED LOADS ARE SUBJECT <br /> O REFUSAL UPON ARRIVAL ONGOING DAILY DELIVERIES MUST BE SCHEDULED WITH THE LANDFILL THE DAY BEFORE <br /> TRANSPORTER r—OPY MANIFEST# r t"1 n A <br />