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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 /> j NON-HAZARDOUS WASTE MANIFEST <br /> GENERATOR WASTE ACCEPTANCE NO. <br /> .. i <br /> I �t.:ii2i; �ai:a az. .;.,t�;i�a,�ae: <br /> MAILING ADDRESS Mail <br /> jj .L.r 'y p A <br /> 1 i .'leak Street. .i�,.i' ,.rde24 '-7311 <br /> CITY, STATE,ZIP REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> (;_,. 941'.110 <br /> U GLOVES U GOGGLES U RESPIRATOR U HARD HAT <br /> PHONE <br /> �,_ �p t, -r^� U TY-VEK U OTHER <br /> CONTACT PERSON SPECIAL HANDLING PROCEDURES: <br /> Robevt (Ira ' <br /> SIGNATURE OF AUTHORIZED AGENT/TITLE DATE <br /> rig 11r717A:C?P,��,-llt lrr _ <br /> �• f 91(/} /j f' .f Pacific Qw&Flesirir. ! i <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 property <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 /> O DISPOSAL U SLUDGE <br /> U CONSTRUCTION U WOOD <br /> U DEBRIS U OTHER <br /> U SPECIAL WASTE <br /> GENERATING FACILITY <br /> i`�aarzticm in$�yciraicrr i?ki)�iY1tS.?Ai <br /> \, <br /> TRANSPORTER NOTES: VEHICLE LICENSE NUMBER TRUCK NUMBER <br /> r r� <br /> ADDRESS 6 <br /> CITY, STATE,ZIP <br /> PHONE END DUMP BOTTOM DUMP TRANSFER <br /> SIGNATUREOF AUTHORIZED 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 /> U SOIL <br /> -REMARKS <br /> O CONSTRUCTION <br /> FACILITY TICKET NUMBER DEBRIS <br /> ❑ NON-FRIABLE <br /> ASBESTOS <br /> SIGNATURE OF AUTHORIZED AGENT DATE <br /> ❑WOOD <br /> U ASH <br /> U SPECIAL OTHER <br /> SCHEDULING MUST BE MADE PRIORTO 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 />