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l i"'Canyon ❑ Ox Mountain El Newby Island [ ForWard <br /> tart' Landfill Sanitary Landfill Sanitary Landfill' Landfill <br /> 1 Bailey Road 12310 San M, teo Road 1601 Dixon Landing Road 9999 S.Austin Road <br /> Pittsburg,CA 94565 Half Moon Ba CA 9401 a 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 /> PHONE <br /> `' 03 "' 0 GLOVES ❑GOGGLES U RESPIRATOR Q~D HAT <br /> 209' U TY VEK U OTHER <br /> CONTACT PERSON SPECIAL HANDLING PROCEDURES: <br /> - a <br /> S GNA R F AUTHORIZED AGENT/TITLE DATE <br /> GENERATOR'S CERTIFICATION:I hereby certify that the above named material isnot a hazardous <br /> waste as defined by 40 CFR Part 261 or title 22 of the California code of regulations,hes been property <br /> described,classified and packaged,and is In proper condition for transportation a-.cording to applicable <br /> regulations;AND,H the waste Is a treatment residue of apreviously 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 /> U DISPOSAL U SLUDGE <br /> U CONSTRUCTION U WOOD <br /> O DEBRIS HER <br /> 0 SPECIAL WASTE <br /> GENERATING FACILITY <br /> RANSPORTER NOTES: VEHICLE LICENSE NUMBER I TRUCK NUMBER <br /> ., <br /> ADDRESS- <br /> C ,STA ; <br /> PHONE ONE "' END DUMP BOTTOM DUMP TRANSFER <br /> S G E AUTHORIZED AGENT OR DRIVER DATE ROLL EF$ FLAT BED VAN DRUMS <br /> CUsIO� <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 a OTHER <br /> U SOIL <br /> REMARKS <br /> U CONSTRUCTION <br /> FACILITY TICKET NUMBER DEBRIS <br /> U NON-FRIABLE <br /> ASBESTOS <br /> SIGNATURE OF AUTHORIZED AGENT DATE <br /> U WOOD <br /> U ASH <br /> U SPECIAL OTHER <br /> $CHEDUUNG MUST BE MADE PRIORTO 3:00 P.M.THE DAY PRIORTO EXPECTED ARRIVAL*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# 372305 <br />