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1 <br /> Koller Canyon Coffln Buttp �Ox Mountain <br /> ' <br /> f l Newby WPM forward <br /> � _If ry Lllli Landfill) Sanitary Landfill Sorb }Y Landfill Landfill Bnlloy noad 2.007P.07? Coffn 5010 R00d 12014 816n <br /> I� <br /> fN01ao Ro0cl 1.nflfOo HOM1 40;���, fI(lallri f 06-i�0�� <br /> MI 61)111) 0A 01605 01*1101 OR 0730 l�l€�If MOO" l�RYf CA 040'I0 f�llpf(0a <br /> f 11011p (026) 466-0000 P110I16 �0d1•),MPS-20-16 Phone (650) 726.1819 Phone (408)945-2800 Pho)neG 219982-42298 <br /> Fax(925)458-9891 Fax (541)745-3826 Fax (650)726-9183 Fax(408)262-2871 Fax (2 9)982.1009 <br /> NON-HAZARDOUS WASTE MANIFEST <br /> I <br /> GENERATOR <br /> WASTE ACCEPTANCE NO. <br /> MAILING ADDRESS <br /> 20500 s0um Ha . 9905 <br /> CITY, STATE, ZIP REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> CA 95104I <br /> I PHONE C1i;GLOVES ❑ GOGGLES ❑ RESPIRATOR IV HARD HAT <br /> ❑TY-VEK WAFETY VEST <br /> C N ACT PERSON <br /> Ameymy SPECIAL HANDLING PROCEDURES:. <br /> SIGNATURE OF AUTHORIZED AGENT/TITLE DATE <br /> GENERATOR'S CERTIFICATION:I hereby certify that the above named material is not a hazardous i <br /> waste as defined by 40 CFR Par[261 or title 22 of the California code of regulations,has been properly <br /> described,classified and packaged,and is in proper condition far transportation according to appiicable i <br /> regulations;AND,If the waste is a treatment residue of s 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 ivith'the-requirementa of'40 CFR Part 268 and is no longer a hazardous waste as defined by <br /> 40 CFR Part 261. - ••• <br /> I <br /> WASTE T t L <br /> n , <br /> ❑CONSTRUCTION ❑WOOD �J�Q <br /> ❑DEBRIS ❑OTHER . <br /> ©SPECIAL WASTE <br /> GENERATING FACILITY <br /> 20500 mash 11*Imre TRACY <br /> TRANSPORTER NOTES: VEHICLE LICENSE NUMB/ER TRUCKNUMBER <br /> r—Ibme Oil EW <br /> ADDRESS- <br /> Pod <br /> DDRESS <br /> CITY, STATE, ZIP <br /> Tgdi,CA 95241 <br /> PHONE END-DU --- - BOTTOM DUMP- TRANSFER <br /> SIGNATURE OF AUTHORIZED AGENT OR DRIVER DATE ROLL-OFFS FLAT-BED VAN DRUMS F <br /> ❑ ❑ ❑ O i <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 DISPOSAL METHOD: (TO BE COMPLETED BY LANDFILL) <br /> is true and accurate. <br /> DISPOSE OTHER <br /> REMARKS ❑ sail <br /> ❑ CONSTRUCTION <br /> F ILITY TICKET NUMBER DEBRIS <br /> - - — ----- o ntont_r-raInQf_r,_ <br /> ASBESTOS <br /> SIGNATU p'OF AUT ORIZED-A ENT ATE,,--I <br /> x7,.. <br /> ❑. OOD f <br /> SH <br /> K * SPECIAL OTH R <br /> `- I <br /> SCHEDULING MUST BE MADE P.1}�l TO 3:00 P.M.THE DAY PRIOR TO EXPECTED ARRIVAL•ANY UNSCHEDULED LOADS ARE SUBJECT <br /> TO'REFUSAL UPON ARRIVAL'' NGOING DAILY DELIVERIES MUST BE SCHEDULED WITH THE LANDFILL THE DAY BEFORE. <br /> Ftev 11109 N5-024 GENERATOR COPY MANIFEST# <br /> i <br />