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❑ Keller Canyon, ❑Coffin Butte ❑Ox Mountain ❑ Newby Island ® Forward <br /> Sanitary Landfill Landfill Sanitary Landfill Sanitary Landfill Landfill <br /> 301 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 /> 'Rcedw atcr 1 t ft <br /> MAILING ADDRESS _ !(�, <br /> 2025 W,lincitm Ave <br /> CITY,STATE,ZIP REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> tx.,clut.�'+T�,fw957 <br /> PH NE GLOVES ❑GOGGLES ❑RESPIRATOR �HARD HAT <br /> O <br /> M-4 41 j.-,i2 U TY VEIL ❑ SAFETY VEST <br /> CONTACT PERSON <br /> Brot.t.'('F.11 SPECIAL HANDLING PROCEDURES: <br /> SIGNATURE OF AUTHORIZED AGENT/TITLE DATE <br />{ GIENERATOR'S CERTIFICATION:I hereby certify that the above namedmaterial is not a hazardous <br /> waste as defined by 40 CFR Part 261 or title 22 of the California coda of regulations,has been properly <br /> described,classified and packaged,and is in proper condition for transportation a-cording to applicable <br /> i regulations;AND,If the waste Is a treatment residua of a 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 />'i 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 /> DISPOSAL 0 SLUDGE <br /> ❑CONSTRUCTION ❑WOOD <br /> ❑DEBRIS ❑OTHER , <br /> O SPECIAL WASTE <br /> GENERATING FACILITY - -- <br /> TRANSPORTER NOTES: VEHICLE LICENSE NUMBER TRUCK NUMBER <br /> ADDRESS - <br /> Z71 <br /> DDRESS - <br /> 1 t, r Rt,d <br /> CIN, STATE,ZIP <br /> PHONE END DUMP BOTTOM DUMP TRASFER <br /> f ;),; a,11+I. ❑ ❑ <br /> SIGNATURE OF AUTHORIZED AGENT OR DRIVER DATE ROLL-OFF(S) FLAT-BED VAN DRUMS <br /> l CUBIC YARDS <br /> I <br /> 1 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 BY LANDFILL) <br /> DISPOSE OTHER <br /> ❑ SOIL <br /> EMARKS, <br /> O CONSTRUCTION <br /> FACILITY TIC ET DEBRIS NUMBER U NON-FRIABLE <br /> ASBESTOS <br /> SIGNATURE OFAUT RIZE AGENT' :.. DATE <br /> k o WOOD <br /> i t i <br /> k .\ .1 <br /> 0 ASH <br /> r <br /> ❑SPECIAL OTHER <br /> SCHEDULING MUST BEAM`ADE PRIOR TO 3:00 P.M.THE DAY PRIOR TO EXPECTED ARRIVAL•ANY UNSCHEDULED LOADS ARE SUBJECT <br /> TO REFUSAL UPON ARRIVAL. ONGOING DAILY DELIVERIES MUST BE SCHEDULED WITH THE LANDFILL THE DAY BEFORE. <br /> GENERATOR COPY MANIFEST# 64925 <br />