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❑ Keller Canyon ❑ ®x 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) 72.6-9183 Fax (408)262-2871 Fax (209) 982-1009 <br /> NON-HAZARDOUS WASTE MANIFEST <br /> GENERATOR WASTE ACCEPTANCE NO. f <br /> •. a"�S„ih!a tgaii i.Y 3.:".4.'..+LS <br /> MAILING ADDRESS <br /> CITY, STATE,ZIP REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> PHONE ❑GLOVES ❑GOGGLES ❑RESPIRATOR ❑HARD HAT <br /> ❑TY-VEK ❑OTHER <br /> CONTACT PERSON <br /> Rol ttatt t,) SPECIAL HANDLING PROCEDURES: <br /> SIGNATURE OF AUTHORIZED AGENT/TITLE DATE <br /> ”"-ilYX i6}EYGL:::![1jXYIfJ Ci' <br /> Pecifi.:utas&E.lrstix f,_ <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 268 and is no longer a hazardous waste as defined by <br /> 40 CFR Part 261. <br /> WASTE TYPE: <br /> ,'DISPOSAL ❑SLUDGE <br /> ❑CONSTRUCTION ❑WOOD <br /> ❑DEBRIS ❑OTHER <br /> ❑SPECIAL WASTE <br /> GENERATING FACILITY <br /> j aT,fS1t�t16SY.� 2.)»�CIi"aJU.I;:sBa~<3'� ��•d1CtiT.;!irQlFaA <br /> J TRANSPORTER NOTES: VEHICLE LICENSE NUMBER TRUCK NUMBER, <br /> ADDRESS <br /> CITY, STATE,ZIP <br /> Win.dsor. CA 954C <br /> PHONE END DUMP BOTTOM <br /> yy DUMP TRANSFER <br /> SIGNA,URE-OF AUTHORIZED AGENT OR DRIVER DATE ROLL-OFF(S) 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 /> ❑ <br /> EMARKS SOIL <br /> ❑CONSTRUCTION <br /> FACILITY TICKET NUMBER DEBRIS <br /> ❑ NON-FRIABLE <br /> ASBESTOS <br /> SIGNATURE OF AUTHORIZED AGENT DATE <br /> ❑WOOD <br /> ❑ASH <br /> I <br /> ❑ SPECIAL OTHER <br /> SCHEDULING MUST BE MADE PRtORTO 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 /> MANIFEST# 3 4, 1 `' �� <br />