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❑ Keller Canyon ❑ Ox Mountain ❑ Newby Island PJForward <br /> Sanitary Landfill Sanitary Landfill Sanitary Landfill Landfill <br /> 901 Bailey Road 12310 San Mateo Road 1601 Dixon Landing Road'i 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 /> Fr,.,..{,.J. . )...,.. <br /> Zb Ei.:'S�LlYi tS.• 1:,n1i�.r t.¢Y'+.i <br /> MAILING ADDRESS <br /> 77 'Bea-ic ',14roet Mali. 1124-A <br /> CITY,STATE,ZIP REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> Nan i..:as 9ol 6 A's <br /> ❑GLOVES ❑GOGGLES ❑RESPIRATOR O HARD HAT <br /> PHONE <br /> (4+5 9/31-31-'1 O TY-VEK ❑OTHER <br /> CONTACT PERSON <br /> @)�lGi z`�,�_tr SPECIAL HANDLING PROCEDURES: <br /> SIGNATURE OF AUTHORIZED AGENT/TITLE DATE <br /> ik-Ahorszed Ap nt i t- <br /> �.�`""�' [Iticifiic(Nis fir"0,00ric r <br /> iwt►1i4: <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 Part261. <br /> WASTE TYPE: <br /> DISPOSAL O SLUDGE <br /> ❑CONSTRUCTION O WOOD <br /> O DEBRIS ❑OTHER <br /> O SPECIAL WASTE <br /> GENERATING FACILITY <br /> ��'$.➢iD �.tir93 �_�'';:�i�r'4b: �t�:i?i a 9t..:�is:yf <br /> TRANSPORTER NOTES: VEHICLE LICENSE NUMBER TRUCK NUMBER <br /> ADDRESS <br /> 970 <br /> CITY, STATE,ZIP <br /> 92 <br /> wwtdsor, CA 954 - <br /> PHONE END DUMP BOTTOM DUMP TRANSFER <br /> 1707 ❑ ❑ '143 <br /> SIGNATURE OFAUTHORIZED AGENT OR DRIVER DATE ROLL-OFF(S) 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 /> DISPOSE OTHER <br /> ❑ <br /> REMARKS SOIL <br /> ❑CONSTRUCTION <br /> FACILITY TICKET NUMBER DEBRIS <br /> O NON-FRIABLE <br /> ASBESTOS <br /> SIGNATURE OF AUTHORIZED AGENT DATE <br /> O WOOD <br /> ❑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 /> GENERATOR COPY MANIFEST# <br />