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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 /> x (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 /> vv :Orr" ftiln.4 'Xw4 <br /> CITY, STATE,ZIP REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> Chariotwe,�' C 282 GLOVES ❑GOGGLES ❑ RESPIRATOR HARD HAT <br /> PHONE <br /> t: �,€y}y Q TY VEK ❑OTHER <br /> CONTAue <br /> CT PERSON SPECIAL HANDLING PROCEDURES <br /> SIGNATURE OF AUTHORIZED AGENT/TITLE DATE <br /> 'ell A <br /> GENERATQRtS CERTIFICATION I hereby certify that the,above named matenal is not a hazardous <br /> waste as defined by 40 CER Part 261 or title 22 of the Ca ifom;a code of regulations has been properly <br /> descnbed 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 the waste has been treated in RECEIVING FACILITY <br /> accordancewith the requirements of 40 CFR Part 268 and is no tenger a hazardous waste as defined by <br /> 40 CFR P&M 265 <br /> WASTE TYPE <br /> '3 DISPOSAL Q SLUDGE <br /> ❑CONSTRUCTION ❑WOOD <br /> ❑DEBRIS ❑OTHER <br /> O SPECIAL WASTE <br /> iTR <br /> E <br /> NNERATING FACILITY <br /> ..01) <br /> ANSPORTER NOTES VEHICLE LICENSE NUMBER TRUCK NUMBER <br /> ADDRESS <br /> 4 <br /> CITY, STATE, ZIP w <br /> PHONE END DUMP BOTTOM DUMP TRANSFER <br /> SIGNATURE OF AUTHORIZED AGENT OR DRIVER DATE ROLL-OFF(S) FLAT-BED VAN DRUMS <br /> it ❑ ❑ ❑ ❑ <br /> zr _ <br /> CUBIC YARDS <br /> 1 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 /> U colvsTRucT1oN <br /> DEBRIS <br /> FACILITY TICKET NUMBER r Q NON-FRIABLE <br /> ASBESTOS <br /> IGNATURE OF AUTHORIZED AGENT i DATE <br /> r ; l ❑WOOD <br /> ❑ASH <br /> ' Q SPECIAL OTHER <br /> SCHEDULING MUST BE MADE PRIORTO 3 00 P M THE DAY PRIOR TO 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 /> -' MANIFEST# �' <br /> GENERATOR CONY I v i u <br />