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❑ Keller Canyon ❑ Ox Mountain ❑ Newby Island [ Forward <br /> k _ Unitary Landfill Sanitary Landfill Sanitary Landfill Landfill <br /> T• 901 Bailey Road 12310 San Mateo Road 1601 Dixon Landing Road 9999 S Austin Road <br /> Pittsburg,CA 94565 Half Moon Bay, CA 94019 Milpitas, CA 95035 Manteca, CA 95336 <br /> Phone (925)458-9800 Phone (650) 726-1819 Phone (408) 945-2800 Phone (209) 982-4298 <br /> Fax(925)458-9891 Fax (650)726-9183 Fax (408) 262-2871 Fax (209) 982-1009 <br /> 0 NON-HAZARDOUS WASTE MANIFEST <br /> GENERATOR WASTE ACCEPTANCE NO. <br /> MAILING ADDRESS 4 <br /> 15-4 G <br /> CITY, STATE, ZIP REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> ` ' aGLOVES ❑GOGGLES ❑ RESPIRATOR W1ARD HAT <br /> PHONE <br /> U TY-VEK U OTHER <br /> CONTACT PERSON <br /> SPECIAL HANDLING PROCEDURES <br /> SIGN,1!�L.ZF3&0,F AUTHORIZE AGENT),TITLE DATE <br /> J i <br /> GERTIFICATfON t hereby certify that the above named material is not a hazardois <br /> waste as defined by 40 CFR Part 261 or title 22 of the California code of regulations has been propefly <br /> described classified and packaged and is in proper condition for transportation a-cording to applicable <br /> regulations AND if the waste is a treatment residue of a previously restricted hazardous waste <br /> subten to the land Disposal Restrictions I certify and warrant that the waste has been trea ed in RECEIVING FACILITY i <br /> accordance with the requirements of 40 GFR Part 268 and is no longer a hazardous waste as defined by <br /> 40 CFR Part 261 <br /> WASTETYPE <br /> ❑DISPOSAL Q SLUDGE <br /> ❑CONSTRUCTION ZI WOOD <br /> •DEBRIS ❑OTHER <br /> ❑SPECIAL WASTE <br /> GENERATING FACILITY <br /> TRANSPORTER NOTES VEHICLE LICENSE NUMBER TRUC NUMBER <br /> 1 1 1 ! I f/ _ , D <br /> ADDRESS <br /> CITY, STATE, ZIP <br /> PHONE END DUMP BOTTOM DUMP TRANSFER <br /> SIGNATURE OFAUTHORIZED AGENT OR DRIVER JDATE ROLL-OFF(S) FLAT-BED VAN DRUMS <br /> 7F <br /> CUBIC YARDS <br /> I hereby certify that the above teamed 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 /> ❑ SOIL <br /> REMARKS <br /> ❑ CONSTRUCTION <br /> DEBRIS <br /> FACILITY TICKET NUMBER ❑ NON FRIABLE <br /> ASBESTOS <br /> SIGNATURE OF AUTHORIZED AGENT DATE <br /> ❑ WOOD <br /> ❑ ASH <br /> U SPECIAL OTHER <br /> SCHEDULING MUST BE MADE PRIORTO 3 00 P M THE DAY PRI ORTO 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 /> SALES COP`,` MANIFEST# _;;, 58 63 <br />