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❑ Keller Canyon ❑ Ox Mountain ❑ Newby Island ® Forward <br /> Sanitary Landfill Sanitary Landfill Sanitary Landfill 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 95336 <br /> Phone (925)458-9800 Phone (650) 726-1819 Phone(408)945-2800 Phone(209) 982-4298 <br /> . Fax�B-9891 Fax (650) 726-9183 Fax (408) 262-2871 Fax (209) 982-1009 <br /> NON-HAZARDOUS WASTE MANIFEST <br /> GENERATOR WASTE ACCEPTANCE NO. <br /> CoxmpafJs r�1-:,1r <br /> MAILING ADDRESS <br /> "UU YoI "-.Qn oa-r <br /> CITY, STATE,ZIP REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> . 'tett.e NlC 222 1 s M GLOVES D GOGGLES U RESPIRATOR Z1 HARD HAT <br /> PHONE <br /> (t N1• f r+67 Q TY-VEK ❑OTHER <br /> CONTACT PERSON SPECIAL HANDLING PROCEDURES <br /> SIGNATURE OF AUTHORIZED AGENT/TITLE DATE <br /> GENERP,TOR S'6ERTIFICATION t hereby certify that the above named material is not a hazardous <br /> waste as defined by 40 CFR Pad 261 or title 22 of the California code of regulations has been properly <br /> deacnbed classified and packaged and is in proper condition for transportation a cording to applicable <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 tate waste has been treated m RECEIVING FACILITY <br /> accordance with the requirements 0140 CFR Part 266 ands no longer a hazardous waste as defined by <br /> 40 CFR Part 261 <br /> WASTE TYPE <br /> Tt7 DISPOSAL d SLUDGE <br /> ❑CONSTRUCTION D WOOD <br /> U DEBRIS U OTHER <br /> D SPECIAL WASTE <br /> GENERATING FACILITY <br /> K00 h 'Resat; T"OC1i0_q <br /> TRANSPORTER NOTES_ VEHICLE LICENSE NUMBER—F TRUCK NUMBER <br /> it T-n d g y t-- <br /> ADDRESS %r <br /> r <br /> 15'353f3•� t}» <br /> CITY, STATE,ZIP <br /> PHONE END DUMP BOTTOM DUMP TRANSFER <br /> ❑` ❑ ❑ <br /> SIGNATURE OF AUTHORIZED AGENTjOR DRIVER DATE ROLL-OFF(S) FLAT-BED VAN DRUMS <br /> f n l 7 r1"" ir' l `,. F•i r/ 6 `� C-...�! <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 U SOIL <br /> U CONSTRUCTION <br /> FACILITY TICKET NUMBER DEBRIS <br /> ❑ NON-FRIABLE <br /> -- ASBESTOS <br /> SIGNATURE OF AUTHORIZED AGENTS DATE <br /> " R; rr ✓ D WOOD <br /> r:F <br /> �U ASH <br /> U SPECIAL OTHER <br /> SCHEDULING MUST BE MADE PRIORTO 3 00 P M THE DAY PRIORTO EXPECTED ARRIVAL•ANY UNSCHEDULED LOADS ARE SUBJECT <br /> TO REFUSAL UPON ARRIVAL ONGOING DAILY DELIVERIES MUST BE SCHEDULED WITH THE LANDFILL THE DAY BEFORE <br /> GENERATOR COPY MANIFEST# ��1 1- <br /> .�� <br />