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u mener Lran on LJGoffin.Butte LJ Ox Mountain LJ Newby Island Forward <br /> Sanitary LandfillLando." Sanitar}�Landfif! .f�nitary Landfill Landfill <br /> 901 Bailey Road 28972 CBtrtte Road 12310 San Mateo Road. 4�b1 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 I <br /> k GENERATOR - . . <br /> . . WASTE ACCEPTANCE NO. <br /> MAILING ADDRESS .. <br /> 20500 S Ha }ire91905 <br /> CITY, STATE;ZIP< REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> 530 <br /> PHONE CKGLOVES ❑ GOGGLES ❑ RESPIRATOR M HARD HAT <br /> . F <br /> ' U TY-VEK CXSAFETY VEST <br /> CON ACT PERSON .-. .. ' <br /> Ame O a: SPECIAL HANDLING PROCEDURES: <br /> SIGNATURE OF AUTHORIZED AGENT 1 TITLE DATE <br /> GENERATOR'S CERTIFICATION:I hereby cerilty that the above named material is not a hazardous ` <br /> waste as defined by 40 CFR Part 261 or title 22 of the Cafifamla code of regulations,has been properly - <br /> described,classified and packaged,end Is In proper condition for transportation according to app9cable <br /> regulations;AND,If 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 /> O„ SPOSAL -❑SLUDGE <br /> CW <br /> I CONSTRUCTION L7 WOOD <br /> ❑DEBRIS , ❑OTHER <br /> ❑SPECIAL WASTE t <br /> GENERATING FACILITY <br /> -20500,SIDU&€00Y Dfive TRACY <br /> TRANSPORTER NOTES: VEHICLE LICENSE NUMBER TRUCK NUMBER I <br /> I <br /> ADDRESSat IVMCC 2M 357' <br /> CITY, STATE, .ZIP it <br /> F,odLCA 95241___ <br /> PHONE END DUMP -BOTTOM DUMP TRANSFER <br /> SIGNATURE OF AUTHORIZED AGENT OR DRIVER DATE ROLL-OFF(S) 'FLAT-BED VAN DRUMS <br /> u _, ❑, ❑ ❑ <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 <br /> Is true and accurate. DISPO AL METHOD: (TO BE COMPLETED BY LANDFILL) <br /> DISPOSE OTHER <br /> .REMARKS - ❑ SOIL <br /> x ❑ CONSTRUCTION G <br /> FACILITY TICKET NUMBER DEBRIS <br /> rU NON-FRIABLE <br /> ASBESTOS Y <br /> SIGNATURE OF AUTHORIZED AGENT DATE <br /> ❑ WOOD <br /> j <br /> ❑ ASH <br /> ❑ SPECIAL OTHER' <br /> S6HEDULING MUST BS MADE 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 /> Rev 11/09 NS-024 GENERATO i COPY. . MANIFEST#i7: a�Mry its, <br />