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III®,n,. ❑ Ox Mountain ❑ Newby Island [ Forward <br /> ry Landfill Sanitary Landfill Sanitary Landfill Landfill <br /> p <br /> ,iley Road 12310 San Mateo Road 1601 Dixon Landing Road 9999 S.Austin Road <br /> *r3ittsburg,CA 94565 Half Moon Bay,CA 94019 Milpitas,CA 95035 -Manteca, ' 533 <br /> Phone(925)458-9890 - - Phone(650)726-1819 Phone(408)945-2800 horse 209 �82- �28 <br /> Fax(925)458-9891 Fax(650)726-9183 Fax(408)262-2871 C; Fax,�( 9) 8z-1 � <br /> NON-HAZARDOUS WASTE MANIFEST <br /> GENERATOR WASTE ACCEPTANCE NO. <br /> MAILING ADDRESS <br /> 61110- <br /> CITY,STATE,ZIP REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> -PHONE <br /> ` Q GLOVES U GOGGLES Q RESPIRATOR O HARD HAT <br /> It 2494 R61 i_g�lcl Q TY VEK Q OTHER <br /> CONTACT PERSON <br /> SPECIAL HANDLING PROCEDURES: <br /> S A AUTHORIZED AGENT/TITLE DATE <br /> ILL <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 title 22 of the California code of regulations,has been properly <br /> classified and packaged,and is in proper condition for transportation a-'ording to applicable <br /> regulations;AND,Hafts 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 268 and is no longer a hazardous waste as defined by <br /> 40 CFR Part 261. <br /> WASTE TYPE: <br /> Q DISPOSAL Q SLUDGE �u <br /> Q'CONSTRUCTION Q WOOD <br /> O DEBRIS Q OTHER <br /> O SPECIAL WASTE <br /> GENERATING FACILITY <br /> RASPORTER NOTES: VEHICLE LICENSE NUMBER TRUCK NUMBER <br /> v <br /> a 7 <br /> PHONE END DUMP BOTTOM DUMP TRANSFER <br /> 60AAMG,FAUTHORIZED AGENT OR DRIVERDATE ROLL-OFFS FLAT-BED VAN DRUMS <br /> CUBIC YARDS <br /> 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 /> REMARKS Q SOIL <br /> Q CONSTRUCTION <br /> FACILITY TICKET NUMBER DEBRIS <br /> D NON-FRIABLE <br /> ASBESTOS <br /> SIGNATURE OF AUTHORIZED AGENT ,,-'DATE <br /> ❑WOOD <br /> d <br /> Q ASH <br /> Q SPECIAL OTHER <br /> SCHEDUUNG MUST BE MADE PRIORTO 3:00 P.M.THE DAY PRIOR TO EXPECTED ARRIVAL a ANY UNSCHEDULED LOADS ARE SUBJECT <br /> TO REFUSAL UPON ARRIVAL. ONGOING DAILY DELIVERIES MUST BE SCHEDULED WITH THE LANDFILL THE DAY BEFORE. <br /> GENERATOR COPY MANIFEST# 372309 <br />