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l_I Keller Canyon ❑Coffin Butte ❑Ox Mountain ❑Newby. Island Forward <br /> Sanitary Landfill Landfill { ^� . Sanitary Landfill Sa�"Miry Landfill Landfill " <br /> 901 Bailey Road 28972 Coffin e Road 1.2310 San Mateo Road 16014T on 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 <br /> WASTE ACCEPTANCE NO. <br /> M ILING ADD ESS ; <br /> '20500 South Holy Drive `� � 9905 <br /> CITY, STATE, ZIP REQUIRED PERSONAL PROTECTIVE-EQUIPMENT <br /> XCA 95304 <br /> PHONE CXGLOVES ❑ GOGGLES ❑ RESPIRATOR 3D HARD HAT <br /> O TY-VEK CXSAFETY VEST <br /> C N TACT PERSON <br /> e <br /> SPECIAL HANDLING PROCEDURES: <br /> SIGNATURE OF AUTHORIZED AGENT/TITLE DATE <br /> i <br /> ' > YXr <br /> r <br /> GENERATOR'S CERTIFICATION:I hereby certify that the above nam material is not a hazardous <br /> waste as defined by 40 CFR Part 261 or title 22 of the Celitomla code of regulations,has been properly <br /> described,classified and packaged,and is improper condition for transportation according to applicable „ <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 •'s ' I <br /> .._accordance.withibe.requiremerits of_4U_CFR Part,268 and is n9 longer_a hazardous waste as defined by y.- <br /> 40 CFR Part 261. <br /> WASTE TYPE: f.. <br /> ❑SLUDGE _ 1 <br /> ❑CONSTRUCTION ❑WOOD v_ <br /> ❑DEBRIS ❑OTHER <br /> ❑SPECIAL WASTE <br /> GENERATING FACILITY <br /> 20500 NOU&H04 Drive TRACY <br /> TRANSPORTER NOTES: VEHICLE LICENSE NUMBER TRUCK NUMBER <br /> _r"n Mmme oil kc <br /> ADDRESS <br /> Pad offim 3 5!7 <br /> CITY, STATE, ZI <br /> PHONE __� � ___ ----.–.END–DUIVIP —BOTTOM_DU_MP TRANSFER <br /> ❑ ❑ <br /> I _ SIGNATURE OF AUTHORIZED AGENT OR DRIVER DATE ROLL-OFFS FLAT-BED VAN DRUMS l <br /> ❑ ❑ ❑ ❑ <br /> CUBIC YARDS <br /> [ hereby certify that the above named material has beenh5 <br /> accepted and to the best of my knowledge the foregoing ; <br /> 15 true and accurate. DISPOSAL METHOD: (TO BE COMPLETED BY LANDFILL) <br /> DISPOSE -•,v..:QHE;R,;,:, <br /> ❑ SOIL <br /> REMARKS <br /> ❑ CONSTRUCTION <br /> FACILI ,TICKET NUMBER DEBRIS <br /> ❑-NON-FRIABLE <br /> ASBEST S <br /> SIGr4ATPRE OF AUTHO LED AGENT TE <br /> ❑ A H , <br /> ❑ SPECIAL THER <br /> SCHEDULING MUST BE MADE PH] R TO 31 P.M.THE DAY PRIOR TO EXPECTED ARRIVAL a ANY UNSCHEDULED LOADS ARE SUI3JECT <br />` TO REFUSAL UPON ARRIVAL. 9 NGOING DAILY DELIVERIES MUST BE SCHEDULED WITH THE LANDFILL THE DAY BEFORE. } <br /> f Rev 11/09 NS-024 GENERATOR COPY MANIFEST 46 2_11 <br />