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Non-Hazardous Waste Manifest
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<br />Non•ilaaardnas Wavr, Man,rest Generator ID Numtun Waste, Profile Number .
<br />PHLF-20-971 L Vi3SI(r T racsing (Manifes)) Number
<br />Bin HB 1018
<br />C.“110Mtm Billing N011it: mil Marling
<br />ANCON
<br />570 Business Park Drive, Suite 110, Lincoln, CA 95648
<br />CL"m" IIIIIMB Phu"' (310) 933-6068
<br />Generator's Site Add' crss
<br />SKS Transport Line Inc.: 11616S Haden Road, Lathrop, CA 95330
<br />GI''''at''' 'I'mi'. (510) 374-2586
<br />,,,..,..i.,, I corn..., No, h , ,,,
<br />—ANGAN- , '/- Vt/Cff filo
<br />US EPA ID Nambor ' 604?
<br />.,r,A99.em-ruets /.7 YN0
<br />Tr ansper ter 2 Cernpany Name US EPA ID Number
<br />Designated Fammy Marne arid Sty Address
<br />Potrero Hills Landfill, Inc.
<br />3675 Potrero Hills Lane, Suisun, CA 94585
<br />Facility's Phone: (707)432-4627
<br />US EPA ID Number
<br />Witrite Shrlffsing Name and Oesclipt 0,,
<br />Containers
<br />Total Quantity t.ii 1 VA !Vol Disposal Method
<br />1 Non-Hazardous Soil and Rock 1 CM 20 V H131
<br />,,,,,,,i.,1-_. ..,ng Instructions arid Additional Information
<br />Wear appropriate PPE when handling. Job #400-13-29708
<br />24 Hour Erne,gency Resaonse Phone
<br />800-556-9090
<br />Enierchnicy Resaunse Guide Num0,
<br />GENERATOR'S I OFFERORS CERT1FICATIDN: I hereby middy trun he altrovedes.ni,E.d matenals are nomhaain dorm wastes as defined by 40 CFR 261 01 any anon able Gate Ian Further, Mal the above 'tuned
<br />materials are properly classified, described. packaged, marked and labeled. A.Ifi n . ' , unditIon tor transportation according to the applicable reffillatiOnS 0 lint Deportment M TioesPOrtattOff
<br />Generator's Offeror's Printed/typed Name 1 /6 1-4140SPLIF Sign:, 'IrN Month
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<br />Day Year
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<br />..,.. - . ...„ --.... / .,.,
<br />Transporters Acknowledgement ut Receipt of Materials
<br />Transporter 1 Printed /Typed Name Signature
<br />Transporter 2 Printed /Typed Name Signature
<br />Discrepancy
<br />Discrepancy Indication Space QI Quantity Q Typo Cl Residue ..1 Partial Rejection '..) Full Refection
<br />Alternate Facilly Or Generator) IN -.,
<br />'irt id c,Z ,
<br />Facil t/s Penne: ('S4,c,.-
<br />US EPA ID Number
<br />Signature al Monate racily tot Genetatod
<br />‘r4St 2 /
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<br />24•1.),
<br />4 "lanai Day,
<br />41447
<br />Designated Facility Creiner m Opei atm. Certification of Receipt ot materials cnverod by the manifest r:krial,k.poelsertOrtichiparics- sec ion
<br />Printed I TyPed Name ...—/.."..m Signature
<br />..sa,
<br />Month Day Year
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