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❑ Keller Canyon ❑ Ox Mountain ❑ Newby Island El 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(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 /> C ""Ju C, atM rx irssiC <br /> MAILING ADDRESS <br /> It 91T 3 � �i , <br /> CITY, STATE,ZIP REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> PHONE 0 GLOVES Q GOGGLES Q RESPIRATOR Q HARD HAT <br /> (4.15 97 3-,3/73 Q TY-VEK Q OTHER <br /> CONTACT PERSON <br /> ? (33ef1 (iR'iiy SPECIAL HANDLING PROCEDURES: <br /> SIGNATURE OF AUTHORIZED AGENT/TITLE DATE <br /> r, (t Pacif c Ghda&}"lector f <br /> M111 <br /> GENERATOR's CERTIFICATION:I hereby certify that the above named material is not a hazardous <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 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 /> 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 /> Q DISPOSAL O SLUDGE <br /> Q CONSTRUCTION O WOOD <br /> D DEBRIS O OTHER <br /> U SPECIAL WASTE <br /> GENERATING FACILITY <br /> TRANSPORTER _ gg NOTES: VEHICLE LICENSE NUMBER TRUCK NUMBER <br /> ADDRESS <br /> CITY, STATE,ZIP <br /> PHONE END DUMP BOTTOM DUMP TRANSFER <br /> SIGNATURE OF AUTHORIZED AGENT OR DRIVER DATE ROLL-OFFS) FLAT-BED VAN DRUMS <br /> ❑ ❑ ❑ ❑ <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 Q SOIL <br /> Q CONSTRUCTION <br /> FACILITY TICKET NUMBER DEBRIS <br /> ❑ NON-FRIABLE <br /> SIGNATURE OF AUTHORIZED AGENT DATE ASBESTOS <br /> Q WOOD <br /> O ASH <br /> O SPECIAL OTHER <br /> SCHEDULING MUST BE MADE PRIORTO 3:00 P.M.THE DAY PRIORTO EXPECTED ARRIVAL a ANY UNSCHEDULED LOADS ARE SUBJECT <br /> TO REFUSAL UPON ARRIVAL. ONGOING DAILY DELIVERIES MUST BE SCHEDULED WITH THE LANDFILL THEDAY BEFORE. <br /> GGt ERAT©R COPY MANIFEST# 'A d 19 Q,7 <br />