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G] Keller Canyon ❑Coffin BE ❑Ox Mountain ❑Ne' hY island <br /> Landfill <br /> Sanitary Landfill Landfill Sanitary Landfill Savary <br /> 901 Bailey Road 28972 Coffin Butte Road 12310 San Mateo Road 1601 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) 9824298 <br /> Fax (925)4SB-9891 Fax (541) 745-3826 Fax (650) 725-9183 Fax (408) 262-2871 ) 00 <br /> NON-HAZARDOUS WASTE MANIFEST <br /> GENERATOR WASTE ACCEPTANCE NO. <br /> M ILING ADD ESS — 91; <br /> 205f.►i?S3�vWa ftol$y�stx L <br /> CITY, STATE, ZIP REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> C?-nVA, GLOVES U GOGGLES U RESPIRATOR T1 HARD HAT <br /> PHONE <br /> U TY VEK CII.SAFETY VEST <br /> CbNTACT PERSON <br /> SPECIAL HANDLING PROCEDURES: <br /> SIGNATURE OF AUTHORIZED AGENT 1 TITLE DATE <br /> s <br /> GENERATOR'S CERTIFICATION:I hereby certily that the above named material is not a hazardous <br /> waste as defined by 40 CFA Part 251 or title 22 of the California code of regulations,has been properly <br /> described,classified and packaged.and is in proper condition[or transportation according to applicable <br /> regulations;AND,If the waste Is a treatment residue of a previously restricted hazardous taste <br /> subject to the Lard!)isposal Restrictions,I certity and warrant that the waste has haen treated i RECEIVING FACILITY <br /> accordance with the regviremernts of 40 GFR Part 268 and is l 6longer a hazardous waste as defined by <br /> 4o CFR Pari 261 <br /> WASTE TYPE: ' <br /> 0fi3fSPOSAIL U SLUDGE <br /> ©CONSTRUCTION J WOOD <br /> J DEBRIS J OTHER <br /> J SPECIAL WASTE <br /> GENERATING FACILITY <br /> 2050P R'fmv�� <br /> TRANSPORTER NOTES: VEHICLE LICENSE NUMBER TRUCK NUMBER <br /> ADDRESS 2 <br /> - <br /> CITY, STATE, ZIP <br /> 2t. C *'► <br /> PHONE END DUMP BOTTOM DUMP TRANSFER <br /> SIGNATURE OF AUTHORIZED AGENT OR DRIVER DATE ROLL-OFF(S) FLAT-BED VAN DRUMS <br /> ' �fi;. <br /> LJ ❑ Li ❑ <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. DISPOSAL METHOD: (TO BE COMPLETED BY LANDFILL) <br /> DISPOSE OTHER <br /> i J SOIL <br /> REMARKS <br /> J CONSTRUCTION <br /> FACILITY TICKET NUMBER DEBRIS <br /> L) NON-FRIABLE <br /> ISBESTOS <br /> SIGNA URE OF AUTH,ORiZEL AGENT DAT <br /> 1r? ; , J. OOD <br /> /f <br /> ASH <br /> ❑ SPECIAL OTHER <br /> SCHEDULING MUST BE MADePRIOR TO 3:00 P.M.THE DAY PRIOR TO EXPECTED ARRIVAL•ANY UNSCHEDULED LOADS ARE SUBJECT <br /> TO REFUSAL UPON ARRI>IFAL.ONGOING DAILY DELIVERIES MUST BE SCHEDULED WITH THE LANDFILL THE DAY BEFORE. <br />