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❑ Keller Canyon ❑ Ox Mountain ❑ Newby Island �, Forward <br /> Sanitary Landfill Sanitary Landfill Sanitary Landfill Landfill <br /> 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 /> NOIR-HAZARDOUS WASTE MANIFEST <br /> GENERATOR 5X 0. WASTE ACCEPTANCE NO. <br /> r-11. —A) ! C� <br /> MAILING ADDRESS <br /> r ,¢ <br /> CITY, STATE, ZIP REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> -5 RE .Al4!? GLOVES U GOGGLES U RESPIRATOR ❑HARD HAT <br /> PHONE <br /> U TY VEK U OTHER <br /> CONTACT PERSON SPECIAL HANDLING PROCEDURES <br /> SIGNATURE OF AUTHORIZED AGENT I TITLE DATE ru 0: L '10.A)7-XI-I l,cJA T9 D <br /> GENERATORS RTIFICATION 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 /> described claesitled and packaged and is in proper condition for tranaportatiop a cording to applicable <br /> regulations AND,It the waste Is a treatment residue 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 /> 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 TYPE <br /> U DISPOSAL U SLUDGE <br /> U CONSTRUCTION U WOOD <br /> U DEBRIS ❑OTHER <br /> U SPMA ASTE X So 14. <br /> GENERATIN CILITY G, <br /> TRANSPORTER f::'" NOTES VEHICLE LICENSE NUMBER TRUCK NUMBER <br /> ADDRESS <br /> CITY,STATE,ZIP <br /> PHONE END DUMP BOTTOM DUMP TRANSFER <br /> ❑ ❑ ❑ <br /> SIGNATURE OF AUTHORIZED AG NT OR DRIVER DATE ROLL-OFFS FLAT-BED VAN DRUMS <br /> CUBIC YARDS <br /> I hereby certify that the above named materlal has been <br /> accepted and to the best of my knowledge the foregoing DISPOSAL METHOD (TO BE COMPLETED BY LANDFILL) <br /> Is true and accur <br /> DISPOSE OTHER <br /> REMARKS O SOIL <br /> ❑CONSTRUCTION <br /> DEBRIS <br /> FACILITY TICKET NUMB U NON-FRIABLE <br /> ASBESTOS <br /> SIGNATURE OFAUTH 28D AGENT DATE <br /> o WOOD <br /> U ASH <br /> U SPECIAL OTHER <br /> SCHEDULING MUST BE MADE PRIOR TO 3 00 P M THE DAY PRIORTO 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 COSY MANIFEST#1 5 0 4 7 7 <br />