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Keller Canyon,, Q Coffin Butte ❑Ox Mountain ❑ Newby Island XForward <br /> Sanitary 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 /> NON-HAZARDOUS WASTE MANIFEST <br /> GENERATOR WASTE ACCEPTANCE NO. <br /> Hea att r Rcsmu om <br /> MAILING ADDRESS _ <br /> 2UD W. iM_ Ave <br /> CITYSTATE,ZIP REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> xn.CA Y5 U.GLOVES I]GOGGLES O RESPIRATOR YU.HARD HAT <br /> PHONE <br /> 4459.062 Ca TY V.EK a SAFETY VEST <br /> CONTACT PERSON.brd <br /> .COR ucn SPECIAL HANDLING PROCEDURES: <br /> SIGNATURE OF AUTHORIZED AGENT/TITLE DATE <br /> GENERATOR'S CERTIFICATION:I hereby certity that the above named material is not a hazardous <br /> waste as defined by 40 CFR Part 261 or title 22 of the California code of regulations,has been properly <br /> described,claasined and packaged;and is In propei condition for transportation a-Lcording to applicable <br /> regulations;AND,If the wens is a treatment residue of a previously restrktsd hazardous waste <br /> subject to the Land Disposai Restrictions,f 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 Pert 261. <br /> WASTE TYPE: <br /> DISPOSAL O SLUDGE <br /> ❑CONSTRUCTION ❑WOOD <br /> i O DEBRIS U OTHER <br /> ❑SPECIAL WASTE <br /> GENERATING FACILITY . <br /> 2025 W.FLazdtou.Avs <br /> TRANSPORTER NOTES: VEHICLE LICENSE NUMBER1 TRUCK NUMBER <br /> Mr.Tru&er <br /> ADDRESS <br /> 2710 Lrarat ds Read <br /> CITY,STATE,ZIP <br /> Uto'HONVA <br /> PHONE END DUMP BOTTOM DUMP TRANSFER: <br /> ( t79 45�i-l1 ❑ <br /> SIGNATURE OF AUTHORIZED AGENT OR DRIVER DATE ROLL-OFFS FLAT-BED VAN DRUMS <br /> . i 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 COMFLE�TED BY LANDFILL) M <br /> Is true and accurate. <br /> DISPOSE OTHER <br /> ❑SOIL. <br /> REMARKS <br /> ❑CONSTRUCTION <br /> FACILITY TICKET NU O ER DEBRIS . <br /> NON-FRIABLE <br /> I ASBESTOS <br /> S! NAT. RE OFA HORIZ D AGENT DATE <br /> O WOOD <br /> i <br /> l]ASH -. <br /> CJ• GI SPECIAL OTHER <br /> SCHEDULING MUST E ADE PRIOR TO 3:00 P M.THE DAY PRIOR t6 EXPECTED ARRIVAL-ANY UNSCHEDULED LOADS ARE SUBJECT <br /> TO REFUSAL UPON-ARRIVAL. ONGOING DAILY DELIVERIES MUST-BE SCHEDULED WITH THE LANDFILL:THE DAY�^BEFOORE. <br /> GENER, jItl,c-00Y MANIFEST# / J [++ <br />