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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(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 /> i w L'h..r_f-'w mss.:;. '.�, ;t_•it�s,:bk.i�. <br /> MAILING ADDRESS AClew <br /> ,_ <br /> CITY,STATE,ZIP REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> E<"'a�;l�£`t"`'y' '" 4F, ❑GLOVES J GOGGLES D RESPIRATOR J HARD HAT <br /> PHONE <br /> �J,s 9 7 3-37"r ❑TY-VEK ❑OTHER I <br /> CONTACT PERSON <br /> SPECIAL HANDLING PROCEDURES: <br /> SIGNATURE OF AUTHORIZED AGENT/TITLE DATE <br /> i-,ge't lot. <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-carding 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 268 and is no longer a hazardous waste as defined by <br /> 40 CFR Part 261. <br /> WASTE TYPE: <br /> , -DISPOSAL 0 SLUDGE <br /> O CONSTRUCTION ❑WOOD <br /> Q DEBRIS ❑OTHER <br /> U SPECIAL WASTE I <br /> GENERATING FACILITY <br /> r <br /> TRANSPORTER NOTES: VEHICLE LICENSE NUMBER TRUCK NUMBER <br /> J�~ i.. <br /> ADDRESS ;,�--� <br /> t <br /> CITY,STATE, ZIP <br /> P <br /> PHONE END DUMP BOTTOM DUMP TRANSFER <br /> --s•-=fit,°;�f .f, �� ❑ ❑ <br /> SIGNATURE OF AUTHORIZED AGENT OR DRIVER DATE ROLL-OFFS) FLAT-BED VAN DRUMS <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 /> I <br /> DISPOSE ; OTHER <br /> O SOIL <br /> EMARKS <br /> U CONSTRUCTION <br /> FACILITY TICKET NUMBER DEBRIS <br /> ❑ NON-FRIABLE <br /> It ASBESTOS <br /> SIGNATURE OF AUTHORIZED AGENT DATE <br /> 'J WOOD <br /> i ❑ASH <br /> ❑ SPECIAL OTHER <br /> SCHEDULING MUST BE MADE PRIOR TO 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 /> G E!N;E[Wi 0R CL'srY MANIFEST# <br />