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LJ Keller Canyon LJ Coffin Butte ❑Ox Mountain ❑ Newby Island IN Forward <br /> .`SAnitary Landfill- Landfill Sanitary Landfill d 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 /> NON-HAZARDOUS WASTE,MANIFEST <br /> GENERATOR WASTE ACCEPTANCE NO. <br /> Headvi d,or Rf olLf <br /> MAILING ADDRESS <br /> . 6939 <br /> Ave — <br /> CITY, STATE,ZIP REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> N GLOVES ❑GOGGLES QR ESPIRATOR AQ HARD HAT <br /> PHONE <br /> -yam ❑TY:VEK- ❑ SAFETY VEST <br /> CONTACT PERSON <br /> Witt Cak>Isrn SPECIAL HANDLING PROCEDURES: <br /> SIGNATURE OF AUTHORIZED AGENT/TITLE DATE <br /> GENERATOR'S CERTIRMION:I hereby cattily that the above named material is not a hazardous <br /> waste as defined by 40 CPR Part 261 or Clio 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,If the waste Is a treatment residue of s previously 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 /> X DISPOSAL ❑SLUDGE <br /> ❑CONSTRUCTION ❑WOOD <br /> 0 DEBRIS ❑OTHER <br /> O SPECIAL WASTE <br /> GENERATING FACILITY <br /> 2025 W,HMItan Ave SrOCKTON <br /> TRANSPORTER NOTES: VEHICLE LICENSE NUMBER TRUCK NUMBER <br /> Mr,Trud:erl �/� .1 a <br /> ADDRESS <br /> V O Lmnis Road GU T .�] <br /> CITY,STATE,ZIP <br /> Si v t OA 95205 <br /> PHONE END DUMP BOTTOM DUMP TR FER <br /> QW1456-11 45 ❑ ❑ ' . <br /> SIGNATU,RE JDF AUTHORIZED AGENT OR DRIVER DATE ROLL-OFFS FLAT-BED- VAN DRUMS <br /> q <br /> CUBIC YARDS <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 OTHER <br /> O SOIL <br /> ARILS 1 ❑CONSTRUCTION <br /> FAC i TIC E NUMB DEBRIS <br /> ❑NON-FRIABLE <br /> f l ASBESTOS <br /> SIG AT E UTHO IZEP AGE T _DATE <br /> ❑WOOD <br /> ❑ASH <br /> ❑SPECIAL OTHER <br /> SCHEDU G MU BE MADE PRIOR TO 3:00 P.M.THE:DAY PRIG TO EXPECTED ARRIVAL-ANY UNSCHEDULED LOADS ARE SUBJECT <br /> TO <br /> REI USAt7UPON ARRIVAL. ONGOING DAILY DELIVERIES MUST BE SCHEDULED WITH THE LANDFILL.THE DAY BEFORE. <br /> OtNERATOR CONY MANIFEST# 6 11 9.V 1 <br />