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p Keller,Canyon E�Coffin Butte ❑Ox Mountain '❑ Newby Island IN Forward <br /> k F>�Sat1italty Landfill Landfill Sanitary,Landfill Sanitary Landfill : Landfill �fR. <br /> 901 Bailey Road 28972 Coffih Butte Road 12310 San Mateo Road 1601 Dixon Landing Road. 9999 S.Austin Road'� ,1 <br /> a` 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(406)945-2804 Phone:(2.09)982-4298. i1 <br /> Fax(925)458-9891 Fax(541)745 3826 Fax(650)726 5183 Fax(408)262-2871 Fax(209)982=1009 ; <br /> NON-HAZARDOUS WASTE MANIFEST <br /> GENERATOR WASTE ACCEPTANCE NO. <br /> H�z1�rt 'finaxx�a : ' <br /> MAILING ADDRESS _ . 6939 <br /> 7410 W,liawltm Ave <br /> CITY,STATE,ZIP - REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> 2 GLOVES O GOGGLES ❑RESPIRATOR IYU HARD HAT:, <br /> PHONE <br /> aO9 469-f1615 ❑TY VEK a SAFETY VEST. <br /> CONTACT PERSON <br /> SPECIAL HANDLING PROCEDURES: <br /> RTdt.CCU li8Cd1 <br /> - SIGNATURE OF AUTHORIZED AGENT/TITLE DATE <br /> a.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 California code of regulations,has been properly <br /> :descrl6ed,clasaiBed end packaged,and is in proper condition for transportation axording to applicable x' x <br /> �.. regulations;AND,If the waste in a treatment residue of a previously restricted hazardous waste <br /> aubjeef t6 the Lead Dlaposal Restrictions,I certify and warrant that the waste has been treated in ': RECEIVING FACILITY <br /> aGCDrdanpe 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 /> DISPOSAL' U,SLUDGE <br /> O CONSTRUCTION d,WOOD <br /> .b DEBRIS ❑OTHER <br /> O SPECIAL WASTE <br /> GENERATING FACILITY <br /> 2W W.HaZeltai Ave S T1]OF4TON. <br /> TRANSPORTER NOTES'° VEHICLE LICENSE NUMBER TRUCK NUMBER <br /> Mr-'Fsv er ' <br /> ADDRESS . <br /> 27tALrsailtisR�tt -� . . a.;. <br /> CITY,STATE,ZIP <br /> PHONE `,END.DUMP BOTTOM DUMP. TRAN FER <br /> C2 ?.45(-114 <br /> SI ATURE OF UTHt RIZED AGENT OR DRIVER DATE `. ROLLOFF S FLAT-BED' 'VAN DRUMS <br /> 7�C _ <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 COMPLETED 8Y LANDFILL? <br /> Is true and accurate. <br /> i <br /> OTHER <br /> Q SOIL ' <br /> EMARKS <br /> ❑CONSTRUCTION <br /> FACILITY TICKET NUMBER DEBR15 <br /> CI NON-FRIABLE <br /> -ASBESTOS <br /> SIGNATURE OF AUTHORIZED AGENT ATE <br /> 7 WOOD <br /> ` ❑ASH <br /> ❑SPECIAL OTHER <br /> $CHEDULING IAUST-BE-MA15E PRIORTO 3:00 P.MANt DAY PRIORTO EXPECTED ARRIVAL a ANY UNSCHEDULED LOADS ARE SUBJECT <br /> TO REFUSAL UPON ARRIVAL. ONGOING DAILY DELIVERIES MUST BE SCHEDULED WITH THE LANDFILL THE DAY BEFORE. <br /> GENERATOR COFY MANIFEST# 564904 <br />