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❑ Keller Canyon <br />Sanitary Landfill <br />901 Bailey Road <br />Pittsburg, CA 94565 <br />Phone (925) 458-9800 <br />Fax (925) 458-9891 <br />❑ Coffin BF -"e <br />Landfill \► <br />28972 Coffin Butte Road <br />Corvallis, OR 97330 <br />Phone (541) 745-2018 <br />Fax (541) 745-3826 <br />❑ Ox Mountain <br />Sanitary Landfill <br />12310 San Mateo Road <br />Half Moon Bay, CA 94019 <br />Phone (650) 726-1819 <br />Fax (650) 726-9183 <br />❑ Ne—by Island <br />SbIlary Landfill <br />1601 Dixon Landing Road <br />Milpitas. CA 95035 <br />Phone (408) 945-2800 <br />Fax (408) 262-2871 <br />NON -HAZARDOUS WASTE MANIFEST <br />iD"Forward <br />Landfill <br />9999 S. Austin Road <br />Manteca, CA 95336 <br />Phone (209) 982-4298 <br />Fax (209) 982-1009 <br />GENERATOR <br />WASTE ACCEPTANCE NO. <br />MAILING ADDRESS <br />_ <br />CITY, STATE, ZIPREQUIRED <br />PERSONAL PROTECTIVE EQUIPMENT <br />_ <br />I '- �' ' t < '- " <br />LJ GLOVES ❑ GOGGLES ❑ RESPIRATOR ❑ HARD HAT <br />❑ TY-VEK U SAFETY VEST <br />PHONE _ c. ?.- i <br />CONTACT PERSON / w^ -Y •, - �,r . co , <br />SPECIAL HANDLING PROCEDURES: <br />SIGNATURE OF AUTHORIZED AGENT / TITLE <br />DATE <br />_zr <br />GENERATOR'S CERTIFICATION: I hereby certify that the above named malenal is not a hazardous <br />waste as defined by 40 CFR Part 261 or bile 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, It the waste Is a treatment residua of a prevlousty restricted hazardous waste <br />subject to the Land Disposal Restrictions, I 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 haea^dous waste as defined by <br />40 CFR Pan 261, <br />RECEIVING FACILITY <br />WASTE TYPE: <br />❑ DISPOSAL ❑ SLUDGE <br />❑ CONSTRUCTION ❑ WOOD <br />❑ DEBRIS _ UbTHER <br />❑ SPECIAL WASTE <br />GENERATING FACILITYr p e. <br />TRANSPORTER T.. , L. _ ;-�,..�_ - <br />NOTES: VEHICLE LICENSE NUMBER TRUCK NUMBER <br />ADDRESS <br />CITY, STATE, ZIP <br />PHONE T .z .' - j ` <br />END DUMP BOTTOM DUMP TRANSFER <br />SIGNATURE OF AUTHORIZED AGENT OR DRIVER <br />DATE <br />ROLL-OFF(S) FLAT-BED VAN DRUMS <br />❑ ❑ ❑ ❑ <br />I 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. <br />CUBIC YARDS <br />DISPOSAL METHOD: (TO BE COMPLETED BY LANDFILL) <br />DISPOSE OTHER <br />❑ SOIL <br />REMARKS <br />❑ CONSTRUCTION <br />DEBRIS <br />FACILITY TICKET NUMBER <br />❑ NON -FRIABLE <br />ASBESTOS <br />SIGNATURE OF AUTHORIZED AGENT <br />DATE <br />❑ WOOD <br />❑ ASH <br />❑ SPECIAL OTHER <br />SCHEDULING MUSTaBE MADE PRIORTO 3:W P' A,1:HE DAY P"RiORTO EXPECTED ARRAIIAL • ANY UNSCHEDULED LOADS ARE SUEWECT <br />TO REFUSAL. ti.' -ON ARRIVAL. ONGOING LCL L'i` C-ELIVEMES V01ST BE SCHOEDULED WIT!' THF LANDFILL. THE DAY BEFORE. <br />C,F:NFRATOR COPI L-' <br />