|
Non-Hazardous Waste Manifest
<br />teon-Hazaido,rs Waste Mantes; 1 Generator ID Manner l'1,n,r, NOY!' NU,LIVI
<br />PHLF-20-971
<br />Waste TI acklrisi (Manifest) Numbe;
<br />Bin HB 1030
<br />, „61,,,,,4, smi,,,4 N1010 aid Marling
<br />ANCON
<br />570 Business Park Drive, Suite 110, Lincoln, CA 95648
<br />Ct15111:11Ct Haling Phone (310) 933.6068
<br />Generator's Se.e Adrift.s1
<br />SKS Transport Line Inc.: 11616S Harlan
<br />G'nrrairrt'c rhn'w: (510) 374-2586
<br />Road, Lathrop, CA 95330
<br />:,-.10,1Comparry Name
<br />/444C-11944 A )olln,4n_ le-uckin
<br />US EPA ID Number C AX0,00 LS 4t 746
<br />-eA99897-31088
<br />T,.,rksr,u,IE,r 2 Connr.ny Norio US EPA ID Number
<br />Designated Facility Name and Site Address
<br />Potrero Hills Landfill, Inc.
<br />3675 Potrero Hills Lane, Suisun, CA 94585
<br />Faclfity's Phone. (707) 432-4627
<br />IS EPA ID Number
<br />Waste Sivoning Name and Description
<br />Conlah,C,
<br />Total Otrantity UnI1 WI !VW Disposal Method
<br />Type
<br />i
<br />Non-Hazardous Soil and Rock 1 CM 20 Y
<br />,
<br />11131
<br />2
<br />3
<br />4
<br />Special 14,,,,,eimg Instruction; and Additional Informario,
<br />Wear appropriate PPE when handling. Job if 400-13-29708
<br />24 Hour 5mergen4T Rea:some Phone
<br />800-556-9090
<br />Emergency Response Guide Number
<br />GENERATORS i OFFERORS CERTIFICATION: I hereby certify 11101 11w aboveeesrribed materials are norelierardeus wastes ns donned by 40 CFR 261 or any apolirnbla
<br />materials are properly classified, described, packaged, marked and labeled, and re In proper condition for transportoPon according le 1 me app,icoble regulations o.
<br />slate law. Full rer.111, I Urn .1h0.0 named
<br />the Department or TranSpo,laliol.
<br />GorplelOes OfIttor', , - , ,• TyDitt, 1,10,re kW ilD Za :WA
<br />0/1 glC1' C)/ S ,S. _
<br />Signature Month
<br />IF_
<br />Day
<br />tl
<br />Year
<br />Laz6
<br />Transtforter'S AcUnowledgement of Receipt of Material
<br />Transporter 'Potted / Typed Name N 0 % l'4 Ic :nature Month It Day 1 Year
<br />Transporter 1 Ponied / Typed Name
<br />? ,
<br />Sign alu, e MOr1111 Von
<br />Discrepancy
<br />Discrepancy Indication Spate U Orianety U Type U Residue 73 Partial RelecI.c • J Full RttellOrl
<br />Nksinalle Faillay lug Genelalcr)
<br />Facility's Phone:
<br />
<br />; Toiy, —€:rn)
<br />US EPA ID Number
<br />. 0 I ts 0-- —
<br />Signature of Alleulate Farley for Generator) Month
<br />DE
<br />"'ILLi; Day
<br />2 1
<br />Tear
<br />y, 20 Desgnated FectSty Owner or Operator . Certification of Receipt of materials covered by Ilie manifest except as noted in Discrepancy Inc en ‘,..4,1....L.
<br />_
<br />-"--,-4.
<br />awned 1 Typed Name Signature Mond,
<br />..... •,,
<br />Day f"--.. vqof
|