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LJKeller canyon LI:Coffin`8utta ❑Ox Mbuntai rl 0 Newby•Island Forward <br /> Sanitary Landfill Land" � Sanitary'Lapdfill Qc' <br /> anitary Landfill. Landfill <br /> 901'Bailey Road 28972 n'Butte Road 12310 San Mateo;Road 01 Dixon Landing Road, . 9999 S.Austin Road <br /> Pittsburg, CA_ 94565 Corvallis,OR 97330 Haff Moon Bay, CA 94019 Milpitas, CA 95035 Manteca, CA 95336 <br /> o 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(660)726-9183 Fax(408).262-2871 Fax (209) 982-1009 <br /> a <br /> NON-HAZARDOUS WASTE MANIFEST <br /> GENERATOR <br /> WASTE ACCEPTANCE NO. i <br /> MAILING-ADDRESS <br /> 3054th So a 6h0 <br /> CITY, STATE, ZIl? REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> Tmey CA 91104 <br /> PHONE CXGLOVES ❑GOGGLES O RESPIRATOR V HARD HAT <br /> CONTACT PERSON ©TY-VEK [XSAFETY VEST <br /> SPECIAL HANDLING PROCEDURES: <br /> SIGNATURE OF AUTHORIZED AGENT I TITLE DATE i <br /> I <br /> .. r <br /> GENERATOR'S CERTIFICATION!I hereby certify that the above named material is not a hazartlous <br /> waste as defined by 40 CFR Part 261 or title 22 of the California code of regulations,has been properly <br /> described,classified and packaged,and Is in proper condition for transportation according to applicable tF <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 treatd i <br /> accordance with the requirements of 40 GFR Part 268 and is no longer a hazardous waste.ed�fined by RECEIVING FACILITY <br /> 40 CFR Part 261. <br /> WASTE TYPE: <br /> O DISPOSAL ❑SLUDGE <br /> ❑CONSTRUCTION ❑WOOD <br /> ❑DEBRIS ❑OTHER <br /> >...,: <br /> ❑SPECIAL WASTE <br /> GENERATING FACILITY <br /> 20500 SOD&kfc�flgr I3a:iv� T14 Alf' ' <br /> TRANSPORTER NOTES: VEHICLE LICENSE NUMBER TRU K NUMBER <br /> ADDRESS" ' <br /> C TY, $I ATE,ZIP <br /> &CA 9_5241 <br /> PHONE. EN DUMP BOTTOM DUMP TRANSFER } <br /> 10 ❑ ❑ <br /> SIGNATURE OF AUTHORIZED AGENT OR DRIVER DATE 7 ROLL"OFFS FLAT-BED VAN DRUMS <br /> f' elf` _ ` 4.• <br /> V14Y . <br /> CUBIC YARDS <br /> 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 /> REMARKS ❑ SOIL <br /> ❑ CONSTRUCTION <br /> FACILITY TICKET NUMBER DEBRIS <br /> ❑ NON-FRIABLE <br /> SIGNATURE OF AUTHORIZED AGENT DATE ASBESTOS <br /> ❑ WOOD <br /> y <br /> ❑ ASH <br /> ❑ SPECIAL OTHER <br /> SCFIEDl7LING MUST 13E MADE PR9011 TO 3:00 P.KTHE DAY PRIOR TO EXPECTED ARRIVAL.ANY UNSCHEDULED LOIAOS ARE SUBJECT .' <br /> TO REI.. SAL UPON ARRIVAL,ONGOING DAILY DEL1VERIiES NIUST:BE SCHEDULED WITH THE LAN DEILLTHE OAY.BEFORE: <br /> �gv 11109rvs 024 GENERATOF4 COPY <br /> ik i <br />