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Cl Keller Canyon ❑Coffin Butte [-I Ox Mountain ❑Newby Island ;k]Forward <br /> Sanitary Landfill LandfL SanitaryLandfill nitary Landfill Landfill <br /> 901 Bailey Road 28972 Co in Butte Road 12310 San Mateo Road Obi 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 (406)945-2800 Phone(209) 982-4298 <br /> Fax(925)458-9891 Fax(541)745-3826 Fax(650)726.9163 Fax(408)262-2871 Fax(209)952-1009 <br /> NON-HAZARDOUS WASTE MANIFEST <br /> GENERATOR WASTE ACCEPTANCE NO. <br /> semgkh SAM <br /> MAILING ADDRESS <br /> 20500 Sotdb H Drive <br /> CITY, STATE,ZIP REQUIRED PERSONAL PROTECTIVE EQUiPMEI4T <br /> R CA 95304 5GLOVES ❑GOGGLES 0 RESPIRATOR 3b HARD HAT <br /> PHONE <br /> .7 ❑TY-VEK 9 SAFETY VEST <br /> CONTACT PERSON <br /> /I`cd4t 2M SPECIAL HANDLING PROCEDURES: <br /> SIGNATURE OF AUTHORIZED AGENT/TITLE DATE <br /> GENERATOR'S CERTIFICATION:I hereby*artily that dhe above named material Is not a hazardous <br /> waste as dsllned by 40 CFA Part 261 or side 22 of the C ldomia code of regulations,has been property <br /> described.classified and packaged,and Is In proper condition for transportation according to applicable <br /> regulations;AND,If the waste is a b"bnent residue of a previously restrtctad hazardous waste <br /> sugect to the Land Disposal Restrictions,I certify and warrant that the waste has been treated Irf RECEIVING FACILITY <br /> accordance with the requirements of 40 CFR Part 268 and Is no longer a!hazardous waste as dtflned by <br /> 40 CFR Part 261. <br /> WASTE TYPE: <br /> O DISPOSAL ❑SLUDGE <br /> ❑CONSTRUCTION ❑WOOD <br /> ❑DEBRIS ❑OTHER <br /> ❑SPECIAL WASTE <br /> GENERATING FACILITY <br /> 205M Soullt Heffy Dine TRACY <br /> TRANSPORTER NOTES: VEHICLE LICENSE NUMBER TRUCK NUMBER <br /> ]rift od <br /> ADDRESS <br /> Post 0111w 11a 352 <br /> CITY, STATE,ZIP <br /> CA 95241 <br /> PHONE END QUMP BOTTOM DUMP TRANSFER <br /> SIGNATURE OF AUTHORIZED AGENT OR DRIVER DATE ROLL-OFFS FLAT-BED VAN DRUMS <br /> r, ❑ ❑ ❑ 0 <br /> OUBIG YARDS <br /> hereby certify that the above named material has been <br /> accepted and to the best of my knowledge the foregoing DISPOSAL METhiOD: . (TO BE COMPLETED BY LANDFILL) <br /> is true and accurate. <br /> DISPOSE= OTHER <br /> 0 SOIL <br /> REMARKS <br /> O CONSTRUCTION <br /> PAC,ILI TI KET NUMBER DEBRIS <br /> ❑ NON-FRIABLE <br /> > ASBESTOS.. <br /> SIG ATl1 . OF A HORIZEi�AGENT DATE <br /> caw D E <br /> 2 <br /> 'CI A H <br /> o Q 9PECIAL O HER <br /> r <br /> $r, <br /> $DHDDUI.111D b>Iy IIE SAA PRfOR TO 900 P.M.THE DAY PRIOR TO ACTED ARAL•AI11F NM>N IlDULED LOAD <br /> i TO.IIEFUEAL UPO Alit VAL.OIIIdO1N0 DAILY Diwitmes I ft*B9 SCNEbULED WITH THE LANDPI .L t T <br /> I <br /> ri......ff n .rtc_n0.i - - GEIdSFiATbf.3 COPY - - - MANIFEST# <br /> . : <br />