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' ❑ Keller Canyon ❑ Ox Mountain ❑ Newby Island Q-Forward <br /> Sanitary Landfill Sar, ry Landfill Sanitary La lilt Landfill <br /> 901 Bailey Road 12310 San Mateo Road 1601 Dixon Landing Road 9999 S Austin Road <br /> Pittsburg,CA 94565 Half Moon Bay, CA 94019 Milpitas,CA 95035 Manteca, CA 95338 <br /> Phone(925)458-9800 Phone(650)726-1819 Phone(408) 945-2800 Phone (209) 982-4298 <br /> Fax(925)458-9891 Fax(650) 726-9183 Fax(408)262-2871 Fax (209) 982-1009 <br /> NON-HAZARDOUS WASTE MANIFEST <br /> GENERATOR WASTE ACCEPTANCE NO. <br /> MAILING ADDRESS — <br /> CITY, STATE,ZIP REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> SZi .f LOVES a GOGGLES ❑RESPIRATOR * ARD HAT <br /> PHONE <br /> 173 13TY VEK C]OTHER <br /> CONTACT PERSON SPECIAL HANDLING PROCEDURES <br /> ac"', <br /> SIGNATURE OF AUTHORIZED AGENT/TITLE DATE <br /> � 7_(1l 1'zz <br /> GENERATORS CERTIFICATION 1 hereby certify that the above named malarial is not a hizardous <br /> waste as defined by 40 CFR Pan 261 or bile 22 of the Catitomia code of regulations has been properly <br /> descnbed classified and packaged and is,n proper candltbon for transportation axordrng to appilmole <br /> regulations AND,If the waste Is a treatment residue of■provlou*restrioted hazardous waste <br /> arialeet to the Land Qisposai Restrictions I codify and warrant that the waste has been treated in RECEIVING FACILITY <br /> accordance with the requirements of 40 CFR Part 268 and is no longer a hazardous waste as defined by <br /> 40 CFA Part 261 <br /> WASTE TYPE <br /> I WSPOSAL ❑SLUDGE _ <br /> ❑CONSTRUCTION ❑WOOD <br /> ❑DEBRIS ❑OTHER s ._ <br /> ID SPECIAL WASTE } <br /> GENERATING FACILITY <br /> !Ltlz �— <br /> TRANSPORTER NOTES VEHICLE LICENSE NUMBER TRUCK NUMBER J <br /> ADDRESS <br /> CITY, STATE,ZIP <br /> S3�t <br /> PHONE END DUMP BOTTOM DUMP TRANSFER <br /> L4cl Is-"- Z 2' 1 ❑ ❑ <br /> SIGNATURE OF AUTHORIZED AGENT OR DRIVER DATE ROLL-OFF(S) FLAT-BED VAN DRUMS <br /> Q ❑ ❑ <br /> CUBIC YARDS <br /> 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 /> ❑ SOIL <br /> REMARKS <br /> ❑ CONSTRUCTION <br /> FACILITY TICKET NUMBER DEBRIS <br /> ` ONON-FRIABLE <br /> ASBESTOS <br /> RIGNATURE OF AUTHORIZED AG,9NT DAT. <br /> 13 WOOD <br /> �❑ASH <br /> �d O SPECIAL OTHER <br /> EDULING MUST BE MADE PRIOR TO 3 00 P M THE DAY PRIOR TO EXPECTED ARRIVAL a ANY UNSCHEDULED LOADS ARE SUBJECT <br /> REFUSAL UPON ARRIVAL ONGOING DAILY DELIVERIES MUST BE SCHEDULED WITH THE LANDFILL THE DAY BEFORE <br /> MANIFEST# 38955 <br />