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❑ Keller Canyon ❑ Ox Mountain ❑ Newby Island Forward <br /> Sanitary Landfill 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 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 /> ` <br /> 'Pacific(1:!S Fs Fk-cftic <br /> ' <br /> MAILING <br /> +�e Street,p <br /> ADDRESS <br /> 17 O(p <br /> CITY STATE,ZIP REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> sartFzmic 't.A9412f�" U GLOVES U GOGGLES U RESPIRATOR U HARD HAT= <br /> PHONE <br /> l`= X415)973-3773 U TY VEK U OTHER <br /> CONTACT PERSON <br /> Robelt Gray SPECIAL HANDLING PROCEDURES: <br /> SIGNATURE OF AUTHORIZED GENT/TITLE DATE N bl,16 <br /> ( fZ U 7 <br /> - GENERATOR'S CERTIFICATION:I hereby certify&Ahe 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 /> described,classified and packaged,and is in proper condition for transportation a-cording to,applicable <br /> regulations;AND,R the waste is a treatment residue of s previously restricted hazardous waste <br /> subject to the Land Disposal Restrictions,t 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 /> ADISPOSAL U SLUDGE <br /> 'Cl CONSTRUCTION U WOOD <br /> U DEBRIS U OTHER <br /> U SPECIAL WASTE <br /> GENERATING FACILITY <br /> NOTES: VEHICLE LICENSE <br /> F7- 190 <br /> ADDRESS - <br /> ;�20 i?eaii?s`ta iN3{. <br /> CITY,STATE,21P <br /> tj to <br /> W;n&or,12A 95492 <br /> PHONE END DUMP BOTTOM DUMP TRANSFER <br /> (70 838-1407 ❑ ❑ <br /> SIGNATURE OF AUTHORIZED AGENT OR DRIVER DATE ROLL-OFF(S) FLAT-BED VAN DRUMS <br /> �' ❑ Q ❑ ❑ <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 /> U SOIL <br /> EMARKS <br /> U CONSTRUCTION <br /> DEBRIS <br /> FACILITY TICKET NUMBER U NON-FRIABLE <br /> ASBESTOS <br /> SIGNATURE OF AUTHORIZED AGENT DATE <br /> U WOOD <br /> U ASH <br /> U SPECIAL OTHER <br /> SCHEDULING MUST BE MADE PRIORTO 3:00 P.M.THE DAY PRIORTO 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 /> GFNFRATnR rOPY MANIFEST# n^n�^ n •(♦ <br />