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LJ 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 <br /> xwBuc �.,a : : ;c,;;ts ; WASTE ACCEPTANCE NO. <br /> MAILING ADDRESS <br /> CITY, STATE,ZIP REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> ---- <br /> PHONE Q GLOVES O GOGGLES Q RESPIRATOR U HARD HAT <br /> 3.g y735_'17-, ` '"' QTY-VEK Q OTHER <br /> CONTACT PERSON <br /> cb,,;.;tl spray SPECIAL HANDLING PROCEDURES: <br /> SIGNATURE OF AUTHO ZED AGENT/TITLE DATE <br /> i�fi I � / i�37 [ii9�Ct �t,Cit;CUC <br /> i <br /> ✓+ f, 4 nyf r�I v 7� IV- <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 I <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 ofa Previously restricted hazardous waste <br /> subject to the Land Disposal Restrictions,1 certify and warrant that the waste has been treated in <br /> accordance with the requirements of 40 CFR Part 268 and is no longer a hazardous waste as defined by RECEIVING FACILITY <br /> 40 CFR Part 261. <br /> WASTE TYPE: <br /> DISPOSAL U SLUDGE <br /> U CONSTRUCTION ❑WOOD <br /> U DEBRIS U OTHER <br /> U SPECIAL WASTE <br /> GENERATING FACILITY <br /> 6.,LPF.)TBIA r.6x. SYS S <br /> TRANSPORTER NOTES: VEHICLE LICENSE NUMBER TRUCK NUMBER <br /> ADDR $. € r b f7i1"­' '7'--'t­ ; <br /> CITY, STATE,ZIPA/fildsot, ("PI <br /> C �p>r5 i2 j <br /> PHONE END DUMP BOTTOM DUMP TRANSFER <br /> SIGNATURE OF AUTHORIZED AGENT OR DRIVER DATE ROLL-OFF(S) FLAT-BED VAN DRUMS <br /> - •\�5, t��'...<�',,.�-, eta�i};�..r.»„. 0'y„ � '' .�t ❑ ❑ ❑ ❑ <br /> CUBIC YARDS <br /> 1 hereby certify that the above named material has been <br /> accepted and to the best of my knowledge the foregoing <br /> is true and accurate. DISPOSAL METHOD: (TO BE COMPLETED BY LANDFILL) <br /> DISPOSE OTHER <br /> REMARKS Q SOIL <br /> U CONSTRUCTION <br /> FACILITY TICKET NUMBER DEBRIS <br /> U NON-FRIABLE <br /> SIGNATURE OF AUTHORIZED AGENTDATE ASBESTOS <br /> U WOOD <br /> U ASH <br /> U SPECIAL OTHER <br /> SCHEDULING MUST BE MADE PRI :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 /> f.G:Ar_il a�-nn nn--., ueuirrn� n At A.” n <br />