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971, ❑ Ox Mountain ❑ Newby Island [ Forward <br /> u Landfill Sanitary Landfill Sanitary Landfill Landfill <br /> 1 Bailey Road 12310 San Mateo Road 1601 Dixon Landing Road 9999 S:Austin Road <br /> x" 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 WASTE ACCEPTANCE NO. <br /> MAILING ADDRESS <br /> CITY,STATE,ZIP REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> AWE" R!"i A 4 0 GLOVES U GOGGLES 0 RESPIRATOR C1HARDHAT <br /> U TY VEK U OTHER <br /> CONTACT PERSON <br /> SPECIAL HANDLING PROCEDURES: <br /> S A AUTHORIZED AGENT/TITLE DATE <br /> GENERATOR'S`CERTIFICATION:I hereby certify that ft above named material is not a hazardous <br /> waste as defined by 40 CFR Part 261 or title 22 of the California code of regulations,has been properly <br /> ,dassifred and packaged,and is in proper condition for transportation a-cording to applicable <br /> regulations;AND,if the waste is 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 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 /> O DISPOSAL U SLUDGE f a-.a)I�kE 4 <br /> ONSTRUCTION U WOOD ��r <br /> O DEBRIS O OTHER <br /> Q SPECIAL WASTE <br /> GENERATING FACILITY <br /> RI\GISPORTER "' NOTES: VEHICLE LICENSE NUMBER TRUCK NUMBER <br /> A� RESSy . 3 <br /> PYNIM END DUMP BOTTOM DUMP TRANSFER <br /> d <br /> A AUTHORIZED AGENT OR DRIVER DATE ROLL-OFF FLAT-BED VAN UM3'' <br /> CUBIC YARDSr"st., <br /> hereby certify that the above named material has been _ '' Fu. ` , <br /> accepted and to the best Of my knowledge the foregoing DISPOSAL METHOD: 'rT0 BE COMPLETED BY LANDFILL) <br /> is true and accurate. LL) <br /> DISO SE :`t+ OTHER <br /> REMARKS O'SOtL <br /> 0 CONSTRUCTION <br /> FACILITY TICKET NUMBER DEBRIS <br /> 0 NON-FRIABLE <br /> ASBESTOS <br /> SIGNA . REOFAUTHORIZEDAGENT DATE <br /> 0 WOOD <br /> 0 ASH <br /> O SPECIAL OTHER <br /> SCHEDULING MUST BE MADE PRIORTO 3:00 P.M.THE DAY PRIORTO EXPECTED ARRIVdL'•ANY UNSCHEDULED LOADS ARE`SUBJECT <br /> TO REFUSAL UPON ARRIVAL. ONGOING DAILY DELIVERIES MUST BE SCHEbULED WITH THE LANDFILL THE DAY BEFORE. <br /> GENERATOR COPY MANIFEST# ' 7 9,a n <br /> i <br />