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❑ Keller Canyon ❑ Ox Mountain ❑ Newby Island Q 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 /> rr ,..-s ` r.� �:` <br /> I ac-i.t3l. t./�[E13 117- L:�'r 4:;.ABRs• <br /> MAILING ADDRESS <br /> a(6FtS i— <br /> CITY, STATE,ZIP REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> art 'Fr �r.�!ac.�► ''.,h C)A 110 Q GLOVES Q GOGGLES D RESPIRATOR O HARD HAT <br /> PHONE <br /> Q TY-VEK ❑OTHER <br /> CON ON` <br /> SPECIAL HANDLING PROCEDURES: <br /> SIGNATURE OF AUTHORIZED AGENT/TITLE DATE <br /> ?vatttul-i cd Agem far- <br /> 1 <br /> q, <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 /> U DISPOSAL U SLUDGE <br /> U CONSTRUCTION Q WOOD <br /> O DEBRIS U OTHER <br /> U SPECIAL WASTE <br /> GENERATING FACILITY <br /> - <br /> k Stt3T'�`f.£S� §.1�•�f'I tEis1i�:.;=i; r?:i Py'f e4f 3�: <br /> TRANSPORTER NOTES: VEHICLE LICENSE NUMBER TRUCK NUMBER <br /> ADDRESS <br /> CITY,STATE,ZIP <br /> PHONE END DUMP BOTTOM DUMP TRANSFER <br /> .c r .. ❑ ❑ <br /> SIGNAT __ "F A TH RIZED AGENT OR DRIVER DATE ROLL-OFFS) FLAT-BED VAN DRUMS <br /> Z11 L11 <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 /> Q CONSTRUCTION <br /> FACILITY TICKET NUMBER DEBRIS <br /> U NON-FRIABLE <br /> SIGNATURE OF AUTHORIZED AGENT DATE ASBESTOS <br /> U WOOD <br /> Q 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 'E 0;. <br />