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Keller Canyon ❑ Ox Mountain � `❑ Newby Island Forward <br /> Sanitary Landfill Sanitary Landfill Sanitary Landfill Landfili <br /> 901 Bailey Fjoad a — t23ia 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-Fax1925)458 98900 Fax(650) 726-91830 19 Fax (408)262-2871 Fax(2 9) 982-10099 <br /> ik" Phone Phone Phone 9 <br /> NON-HAZARDOUS WASTE MANIFEST <br /> GENERATOR,rt - �_ ' _ WASTE ACCEPTANCE NO.T7 z <br /> j <br /> f f <br /> MAILING ADDRESS <br /> CITY, STATE,ZIP; REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> ❑GLOVES 0 GOGGLES Q RESPIRATOR ❑HARD HAT <br /> PHONE <br /> ❑TY VEK a OTHER <br /> CONTACT PERSONf SPECIAL HANDLINGPPROCEDURES <br /> r <br /> SIGNATURE OF AUTHORIZED AGENT 1TITLE DATE t _ <br /> Y <br /> GENERATOR S CERTIFICATION i hereby certify that the above named material w not a hazardous <br /> waste as defined by 40 CFR Part 261 or title 22 of the California code of regulations has been property <br /> dasonbad classified and packaged and is in proper condom for transportation a cording to applicable <br /> regulations AND If the waste Is a treatment residus of s previously restricted hazardous waste <br /> subject to the Land Disposal Restrictions I certify and warrant that the waste has been treated m RECEIVING FACILITY <br /> accordance with the requirements of 40 CFR Part 266 and is no longer a hazardous waste as defined by <br /> 40 CFR Part 261 <br /> WASTE TYPE <br /> O DISPOSAL Q SLUDGE <br /> O CONSTRUCTION U WOOD <br /> O DEBRIS £�[ OTIR <br /> ❑SPECIAL WASTE <br /> GENERATING FACILITY <br /> t�� <br /> ff 'F F <br /> pjf' <br /> RA�NSP�ORTER f — , rrP NOTES VEHICLE LICENSE NUgMBER TRUCK NUfiABER <br /> ADDRESS E <br /> CITY,STATE,ZIP <br /> PHONE END DUMP BOTTOM DUMP TRANSFER <br /> SIGNATURE OF AUTHORIZED AGENT OR DRIVER <br /> DATE ROLL-OFFS FLAT-EBED VAN DRUMS <br /> �"L d ❑ ❑ ❑ + <br /> _ CUBIC YARDS <br /> r <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 8Y aNDFILL) <br /> Is true and accurate <br /> DISPOSE ' OTHER <br /> O SOIL <br /> EMARKS ❑CONSTRUCTION <br /> DEBRIS <br /> FACILITY TICKET NUMBER ❑NON-FRIABLE <br /> ASBESTOS <br /> t:z <br /> OFAUTHORIZED AG T DATE <br /> U woos <br /> It ❑ASH <br /> h, <br /> f , ❑SPECIAL OTHER <br /> SCHEDULIkG MUST BE MADE PRI04T6 3 0 P M THE DAY PRIORTO EXPECTED ARRIVAL a ANY UNSCHEDULED LOADS ARE SUE3JECT <br /> �TO REFUSAL UPON ARRIVAL ONGOING DAILY DELIVERIES MUST BE SCHEDULED WITH THE LANDFILL THE DAY BEFORE <br /> MANIFEST v <br />