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LJ Keller Canyon El Coffin Butte Cl Ox Mountain C1Newby island IN Forward T <br /> Sanitary Landfill Landfill Sanitary Landfill -Sanitaly Landfill 1 Landfill <br /> 901 Bailey Road 28972 Coffin Butte Road 12310 San Mateo Road 1601 Dixon Landing Road I 9999 S.Austin Road <br /> I ; Pittsburg,CA 94565 Corvallis,OR,97t330 Half Moon Bay,CA 94019 Milpitas, CA 95035 Manteca,CA 95336 " <br /> Phone(925)458-9800 Phone j�4i)745-2018 Phone(650)726.1819 Phone(408)945-2800 Phone(209)982-4298 <br /> Fax(925)456-9891 . Fax(541)745-3826 Fax(650)726.9183 Fax(408)262-2B71 Faz(209)982-1009 <br /> NON-HAZARDOUS WASTE MANIFEST <br /> GENERATOR WASTE ACCEPTANCE NO. <br /> H�t�rMa•Resl;a1 <br /> MAILING ADDRESS <br /> 7.11323 W.Hualm vie <br /> CITY, STATE,ZIP REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> M0ddXT4CA 95203 <br /> PHONE 5GLOVES Q GOGGLES ❑RESPIRATOR Y]HARD HAT <br /> � � � . � <br /> Z 469d625 ❑TY VEK O 9AFETY VEST <br /> CONTACT PERSON <br /> Srdt• SPECIAL HANDLING.PROCEDURES: <br /> Gc1tt r+t>u <br /> SIGNATURE OF AUTHORIZED AGENT/TITLE DATE <br /> GENERATOR'S CERTIFICATION:I hereby certify that the above named material is not a hazardous . <br /> waste as defined by 46 CFR Part 261 or title 22 of the California code of regulations,has been properly <br /> described,classified and packaged,and is In proper condliion for transportation a-carding to applicable <br /> regulations;AN%N the waste to a treatment residue of a previously restricted hazardous waste <br /> subject to the Lend Disposal Restrictions,I certify and warrant that the waste has bean treated in RECEIVING FACILITY <br /> accordance with the requirements of 40 CFR Pert 268 and is no longer a hazardous waste as defined by <br /> 40 CFR Part 261. <br /> WASTE TYPE: <br /> :b DISPOSAL ❑SLUDCE <br /> ❑CONSTRUCTION ❑WOOD <br /> ❑DEBRIS ❑OTHER <br /> ❑SPECIAL WASTE <br /> GENERATING FACILITY <br /> 21W W.Hazettoili Ave S I R"Tt N <br /> TRANSPORTER NOTES: VEHICLE LICENSE NUMBER TRUCK NUMBER <br /> Mr.Ttvriet <br /> ADDRESS J � �1 T <br /> 771OLoaTt s Rmd <br /> CITY,STATE,ZIP <br /> o�ko�OA:57,05 <br /> PHONE END.DUMP BOTTOM DUMP TRANSFER, <br /> _Qn 456-1145 ❑ Q em <br /> SIGNATURE F AUTHORIZED AGENT OR DRIVER DATE ROLL-OFF(S) FLAT-BED- VAN DRUMS', <br /> CUBIC YARDS <br /> hereby certify that the above named material has been <br /> accepted and to the best of my knowledge the foregoing <br /> Is true and accurate. DISPOSAL METHOD: (TO BE COMPLETED 13Y LANDFILL) <br /> DISPOSE OTHER <br /> REMARKS ❑,SOIL <br /> ❑CONSTRUCTION <br /> FACILITY TICKET NUMBER DEBRIS <br /> ❑NON-FRIABLE <br /> ASBESTOS <br /> SIGN TURF OF AUTHOR IZE AGENT DATE <br /> ❑WOOD <br /> �y' �'� �• �� ❑ASH - <br /> ❑SPECIAL OTHER <br /> SCHEDULING MUST BE MADPRIORTO 3:00 P.M.THE DAY PRIORTO EXPECTED ARRIVAL•ANY UNSCHEDULED LOADS ARE SUBJECT <br /> TO REFUSAL UPON ARRI jAL. ONGOING DAILY DELIVERIES MUST BE SCHEDULED WITH THE LANDFILL THE DAY BEFORE. <br /> GENERATOR COPY MANIFEST# 564971 <br /> (Rl{.Q <br />