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Non-Hazardous Waste Manifest
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<br />Nort.Harat nous Waste Manor, We L.te nionle NI,rnbor
<br />PHLF-20-971
<br />Waste Trecking (Manifest) NVIIII, I
<br />Bin HB 1013
<br />c,,,40,,,,,, tiiiiii,g Name and /Marline
<br />ANCON
<br />570 Business Park Drive, Suite 110, Lincoln, CA 95648
<br />nwonier Killing Phone: (310) 933.6088
<br />Generator's Site Address
<br />SKS Transport Line Inc.: 11616S Harlan Road, Lathrop, CA 95330
<br />Gm:rattles Phone: (510) 374-2586
<br />Tfansporier 1 Company Name
<br />4 ANCON AA-1A-d '0 ii(-4 /,-I-L 1k ' 1
<br />US EPA ID Number cligeh 6 i S-ki
<br />,..-CA99807471188._ )qt
<br />Transporter 2 Crirremny Name i US EPA ID Number
<br />Designated Facility Name and Site Address
<br />Pot rero Hills Landfill, Inc.
<br />3675 Potrero Hills Lane. Suisun, CA 94585
<br />Facility's Phone: (707)432-4627
<br />US EPA ID Number
<br />Waste Shipping Name and Description Total Ouantrly Linn Wt / Vol. Disposal Method
<br />1
<br />1 Non-Hazardous Soil and Rock 1 CM 20 Y H131
<br />,
<br />4
<br />Special Handling Instructions and Additional Iniormation
<br />Wear appropriate PPE when handling. Job #400-13-29708
<br />:4 HOW Emergency Response Phone
<br />800-556-9090
<br />Emer gency Response Guido Numb,:
<br />GENERATORS / OFFEROR'S CERTIFICATION. I hereby certify that the above-described materials are non-hazardous wastes as defined by 40 CFR 261*' any applr able state law Further, that the above named
<br />materlaIS are properly claSsIlied. described. packaged. marked and labeled, and are In rxoper condition for transportation according lo the applicable restulatioas o the Department of Transportallort.
<br />Goner ;nes Offer or's Printed / Typed Name .9 .s
<br />li_iist_ ' , /AL. fo , §)/11kme
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<br />Signature e....,./1. /7.-•••1/4
<br />.... __...._ ,..., .__. . .
<br />Month
<br />A
<br />Day YD
<br />Transporter's Acknowledgement of
<br />' TRANsPoP.TER SF_CT1C,IN _
<br />Recelot cdMaterrals
<br />Trans te 1Printed / Typed
<br />i And
<br />/1.— Signature Nomh .
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<br />Day
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<br />Trans, vrtor '2 Premed / Typed Name Si71,1,ure Month DaV `foal
<br />1
<br />SIIIIIIIIIIIK 4 r -.
<br />-_
<br />Discrepancy
<br />Drscrepancy Indication Space i...1 Chianti, Cl Type _I Partial Rejection a Full Rejection
<br />Alternate Faddy lot Geneiatur)
<br />Facthlyi Phone: et>,
<br />US EPA ID Number
<br />r4.1„.
<br />Signature of Alternate Facility (or Generator) "VT,,,,,
<br />:
<br />ISInnth
<br />7 n
<br />DAV Year
<br />Designated Facility Owner, or Operator: Certification of Receipt of onaterlals covered by the manifest except 4,s nattii2 ctisr newt-lion '4- 1/4,
<br />Psi/red / Typed Name
<br />4' t7 ( 1 Signature • .
<br />t.7 "t/b.
<br />C•<-
<br />. ) I Day I Year
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