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U Keller Canyon ❑ Ox Mountain ❑ Newby IslandForward <br /> Sanitary Landfill Sanitary Landfill Sanitary Landfill )OLandfill <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 ,,,e CY WASTE ACCEPTANCE NO. <br /> i <br /> MAILING ADDRESS f y f�tf�ca <br /> 77 .:iii e 'StTect ?Lbil Code.e �124.11a <br /> CITY,STATE,ZIP REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> PHONE <br /> �all ,- ❑GLOVES ❑GOGGLES ❑RESPIRATOR O HARD HAT <br /> I:-E'^1 `;'.._tl_j,,��= O TY-VEK 0 OTHER <br /> CONTACT PERSON <br /> o G.a, <br /> SPECIAL HANDLING PROCEDURES: <br /> ay <br /> SIGNATURE OF AUTHORI ED AGENT/TITLE DATE <br /> ley <br /> /4. l .11U1,1SC Off.<':.'.Flkl L <br /> ✓"Y y I. <br /> t�+asf3�` <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 /> )4'bISPOSAL ❑SLUDGE <br /> ✓O CONSTRUCTION O WOOD <br /> ❑DEBRIS U OTHER <br /> O SPECIAL WASTE <br /> GENERATING FACILITY <br /> TRANSPORTER NOTES: VEHICLE LICENSE NUMBER TRUCK NUMBER <br /> ADDRESS <br /> CITY, STATE,ZIP[[ <br /> PHONE ,a _ END DUMP BOTTOM DUMP TRANSFER <br /> SIGNA t, F AUTHORIZED GENTIORtRIVER DATE ROLL-OFF(S) FLAT-BED VAN DRUMS <br /> 4 f <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 /> EMARKS U SOIL <br /> U CONSTRUCTION <br /> FACILITY TICKET NUMBER DEBRIS <br /> U NON-FRIABLE <br /> SIGNATURE OF AUTHORIZED AGENT DATE ASBESTOS <br /> U WOOD <br /> U ASH <br /> U SPECIAL OTHER <br /> SCHEDULING MUST BE MADE PRIORTO 3:00 P.M.THE DAY PRIORTO EXPECTED ARRIVAL a 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# 4 1 R F; <br />