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❑ Keller Canyon .0 Coffin Butte ❑Ox Mountain ❑Newby island IX Forward . <br /> S44tary Landfill Landfill Sanitary Landfill „ Sanitary Landfill Landfill <br /> 901 Bailey Road 28972 Coffin Butte Road- 12310 San Mateo Road 1601 Dixon Landing Road 9999.S.Austin Road <br /> Pittsburg,CA 94565 Corvallis,OR 97330 .,.Half Moon Bay,CA 94019 Milpitas, CA 95035 Manteca,CA 95336 <br /> Phone(925)458-9800 Phone(541)745-2018 Phone (650)726-1819.' Phone(408)945-2800 Phone(209).982-4298 <br /> Fax(925)458-9891 Fax(541)745-3826 Fax(650)726-9183 Fax(408)262.2871 Fax(209)982-1009 <br /> it i <br /> NON-HAZARDOUS WASTE MANIFEST <br /> GENERATOR ' WASTE ACCEPTANCE NO.. <br /> MAILING ADDRESS ' <br /> 2925 W, vc 6939 <br /> CITY, STATE,ZIP REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> 3t ,cntCA 95203 <br /> PHONE � �GLOVES ❑GOGGLES O RESPIRATOR 3 HARD HAT <br /> (2LOZ 469-060 ❑`TY VEK a SAFETY VEST � <br /> CONTACT PERSON <br /> Brdt.CoWam 4SPECIAL HANDLING PROCEDURES: ' <br /> SIGNATURE OF AUTHORIZED AGENT 1 TITLE DATE <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 Cel%rnia code of regulations,has been property <br /> described,classified and packaged,and is In proper condition for transportation a-xording to applicable <br /> regulations;ANt>,if the waste Is a treatment residue of a previously restricted hazardous waste <br /> aubiect ro 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 /> 40CFR Part 261. _ - <br /> WASTE TYPE: <br /> DISPOSAL ❑SLUDGE <br /> ❑CONSTRUCTION ❑WOOD <br /> ❑DEBRIS ❑OTHER <br /> ❑.SPECIAL WASTE <br /> GENERATING FACILITY <br /> 2W W.Hamtho Ave STOrB.70N <br /> sA TRANSPORTER NOTES: VEHICLE LICENSE NUMBER TRUCK NUMBER <br /> Mr.Tru&er <br /> ADDRESS ,, d2 . J <br /> 2710 Itis R+aa . <br /> CITY,STATE;ZIP <br /> M&Ra-il,,CA 95205 <br /> PHONE END DUMP BOTTOM DUMP .TRANSFER-- <br /> (2" <br /> RANSFER-(Z 45&1145 ❑ ❑ rr: <br /> SIGNATURE FAUTHORIZED AGENT OR DRIVER. DATE ROLL-OFFS FLAT-BED VAN DRUMT-.., , <br /> Ila '16-2 <br /> CUBIC YARDS ,•:, <br /> I hereby certify that the above named material has been <br /> accepted and to the best of my knowledge the foregoing DISPOSAL METHOD:' (TO.BE COMP�LETD BY LANDFILL) <br /> Is true and accurate.` <br /> DISPOSEOTHER.: <br /> ❑ - � <br /> REMARKS 501E <br /> ❑CONSTRUCTION: <br /> FACILITY TICKET NUM. ER DEBRIS <br /> ❑NON-FRIABLE <br /> ASBESTOS <br /> SIGNAT RE OFRUTH IZED AGENT DATE <br /> ` U ASH 4 <br /> ❑SPECIAL OTHER <br /> . f <br /> kkEDULING MUST BE MADE PR IOf TO 3:000.1t.tHE DAY PRIOR TO EXPECTEo ARRIVAL a ANY UNSCHEDULED LOADS ARE SUBJECT <br /> tO REFUSAL UPON ARRIVAL. ONGOING DAILY DE=LIVERIES MUST BE S&GOO.ED WITH THE.LANDFILL THE DAY BEFOREz:: <br /> GENERATOR COPY MAST# p �F-" [7 O <br /> ., <br />