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r <br />❑ Keller Canyon <br />Sanitary Landfill <br />90i Bailey Road <br />Pittsburg, CA 94565 <br />Phone(925)458-9800 <br />Fax (925) 458-9891 <br />❑ Coffin Butte <br />Landfill <br />28972 Coffin Butte Road <br />Corvallis, OR 97330 <br />Phone (641) 745-2018 <br />Fax (541) 745-3826 <br />0 Ox Mountain <br />Sanitary Landfill <br />12310 San Mateo Road <br />Halt Moon Bay, CA 94019 <br />Phone (650) 726-1819 <br />Fax (650) 726-9183 <br />❑ Newby Island <br />Sanitary Landfill <br />16Q1 Dixon Landing Road <br />Milpitas, CA 95035 <br />Phone(408)945-2800 <br />Fax (408) 262-2871 <br />NON -HAZARDOUS WASTE MANIFEST <br />Forward <br />ndfill <br />9999 S. Austin Road <br />Manteca, CA 95336 <br />Phone (209) 982.4298 <br />Fax (209) 982-1009 <br />GENERATOR <br />WASTE ACCEPTANCE Na <br />ui�r nc <br />MAILING ADDRESS <br />J 10 <br />CITY, STATE, ZIP <br />REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br />G <br />GLOVES ❑ GOGGLES ❑ RESPIRATOR XHARD HAT <br />0 TY VEK SAFETY VEST <br />PHONE <br />0 — <br />CONTACT PERSON <br />SPECIAL HANDLING PROCEDURES: <br />WQ�tof Lt A <br />SIG -URE OF AUTHORIZED AGENT /TITLE DATE <br />A? ;',,,. alrg��3 <br />GE11E11AT FM CERTIFICATION: I hereby aarft C1at pre above namad material is rrot a hazardous <br />waste as defined by 40 CFR Part 261 or bib 22 of the Caltornia dodo of regurtatkm, hea been properly <br />domed dessified E11d padmged, and is in proper condition for bael5porfStion e^cordheg t0 applicable <br />regtdatiar>g: ANq, tt 111, weal, is a treebneffl residue of a prarbwiy nmtr%nad hazardous waste <br />Land Disposal e . tgeaas a to <br />cewit are nnis 40 CFR Part � a+ is noto gerhazardous wasteen "aw in <br />by <br />d0 CFA Part 251. <br />[WASTE <br />RECEIVING FACILITY <br />TYPE: <br />❑ DISPOSAL ❑ SLUDGE <br />❑ CONSTRUCTION 0 WOOD <br />❑ DEBRIS ❑ OTHER <br />❑ SPECIAL WASTE <br />GENERATING FACILITY <br />a� S S Sova. R:r w k- W Shu mak. w ►-, <br />TRANSPORTER <br />NOTES: VEHICLE LICENSE NUMBER UCK NUMBER <br />7_4K <br />END DAMP BOTTOM DUMP TRANSFER <br />ADDRESS <br />4410 WjV%d$(ZMA_ <br />CITY, STATE, ZIP <br />PHONE <br />a 6111 I <br />all <br />SIGNATURE OF AUTHORIZED AGENT OR DRIVER DATE <br />ROLL -Off @) 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 <br />is true and accurate. <br />DISPOSAL METHOD: (TO BE COMPLETED BY LANDFILL) <br />DISPOSE OTHER <br />Q SOIL <br />VE—MARKS <br />0 CONSTRUCTION <br />DEBRIS <br />FACILI CKET NUMBER <br />❑ NON -FRIABLE <br />ASBESTOS <br />SIG U E OF AUTHORIZED AGENT <br />WOOD <br />ASH <br />❑ SPECIAL OTHER <br />