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s <br /> ❑ Keller Canyon. ❑.Coffin Butte ❑Ox Mountain ❑Newby Island` Forward <br /> Sanitary Landfill, Landfill Sanitary Landfill Sanitary Landfill andflll <br /> 907 Ejailey 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 /> GENERA roR WASTE ACCEPTANCE NO. <br /> MAILING ADDRESS I <br /> CITY STATE;ZIP REQUIRED PERSONAL PROTECTIVE EQUIPMENT '. <br /> It mt" or ii:zGLOVES ❑GOGGLES ❑RESPIRATOR j2r9ARD'HAT <br /> PHONE. .. <br /> O�Y-VEK SAFETY VEST <br /> CONTACT PERSON j <br /> _ SPECIAL HANDLING PROCEDURES:' <br /> SIGNATURE OF AUTHORIZED AGENT/TITLE DATE <br /> iN, l <br /> GENERATOR'S CERTIFICATION:I hereby Certify that the abov coed material;s net a hazardous <br /> waste as defined by 40 CFR Part 26t or fide 22 of the Califon' Code of regulations,has been property <br /> - <br /> described,:dassffied and packaged,and is in proper condition for transportation a-cording-to applicable <br /> regulations;AND,It the waste Is a treatment residue of a previously restricted hazardous waste <br /> .subject to ft 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 PE.: <br /> ISPOSAL - ❑SLUDGE <br /> •CONSTRUCTION ❑WOOD <br /> O DEBRIS ❑OTHER . <br /> O SPECIAL WASTE <br /> GENERATING FACILITY a <br /> TRANSPORTER N TES: .VEHICLE LICENSE NUMBER TRUCK NUMBER <br /> ADDRESS C`- <br /> CITY,STATE,ZIP <br /> PHONE END DUMP BOTTOM DUMP TRANSFER <br /> SIGNATURE OF AUTHORIZED AGENT OR DRIVER DATE ROLL-OFF(S) . FLAT-BED VAN DRUMS <br /> ❑ ❑ ❑ ❑ <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 /> I <br /> ❑SOIL <br /> REMARKS. i <br /> O CONSTRUCTION <br /> FACILITY TICKET NUMBER DEBRIS <br /> ID NON-FRIABLE <br /> 4 ASBESTOS <br /> SIGNATURE OF AUTiHORt2JED N \ •DATE <br /> WOOD <br /> i <br /> I <br /> O ASH <br /> I <br /> SPECIAL OTHER <br /> SCMEDt.FUNG MUST BE MADE PRIORT0 3:00 R .'TIDE DAY PRIOR TO EXPECTED ARRIVAL.®.Amy umscHEDULED LO ARE SUBJECT <br /> TO REFUSAL UPON ARRIVAL, ONGOING DAILY DELIVERIES M'iJ T � SCHEDULED WffH THS L,A DFS L.L.THE DAY BEFORE. <br /> MANIFEST# C-, � 7 <br />