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LJ Keller Canyon <br />Sanitary Landfill <br />901 Bailey Road <br />Pittsburg, CA 94565 <br />Phone (y25) 458-9800 <br />Fax (925) 458-9891 <br />❑ Coffin Butt( <br />Landfill 1 ' <br />28972 Coffin Butte Road <br />Corvallis, OR 97330 <br />Phone (541) 745=2016 _ <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 />❑ New' Island <br />Samir* 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 />[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 />G ADDRESS <br />1 _ <br />CITY, STATE, ZIP <br />REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br />'57"'s(24< <br />O ,Q/ES OGGLES ❑ RESPIRATORSHARD HAT <br />� i1 <br />❑ TY-VEK ASAFETY VEST <br />PHONE <br />iJJ (O <br />CONTACT PERSON <br />SIGNATURE OF AUT ORIZED AGENT / TITLE 11DATE. <br />SPECIAL AANBLING PROCEDURES: <br />- <br />GENERATORS CERTIFICATION: I hereby codify that the above named material Is not a hazallous <br />waste as defined by 4o CFR Pad 261 or title 22 of the California code of regulations, hes been properly <br />described, classifted and packaged, and is in proper condition for transportation according to applicable <br />regulations; AND, If the waste Is a treatment residue of a previously restricted hazardous waste <br />subject to the Lard Disposal Restrictions, Icar* and warrent that to waste has been treated in <br />accordance with thio requirements of 40 CFR Pert 266 and Is no longer a hazardous waste as defined by <br />- 40 CFRPart 261. - <br />RECEIVING FACILITY <br />WASTE TYPE: <br />,�7DISPOSAL ❑ SLUDGE <br />❑ CONSTRUCTION EAWOOD <br />❑ DEBRIS ❑ OTHER <br />❑ SPECIAL WASTE - <br />GENERATING FACILITY <br />TRANSPORTER <br />NOTES: <br />NNW <br />VEHICLE LICENSE NUMBER iiiiiii�TRU K NUMBER <br />Mlyiddefo <br />�tS3s2`� <br />ADDRESS <br />S i s Y <br />CITY, TATE, ZIP - <br />END DUMP BOTTOM DUMP TRANSFER <br />9IGNATUFjE OF OTHORIZED AGE14f R DRIVER <br />[i T <br />ROLL -OFFS FLAT-BED VAN DRUMS <br />t. <br />❑ ❑ ❑ ❑ <br />I hereby certify that the above named -material has been <br />accepted and to the best of my knowletlge 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 TICWT N BER <br />O NON -FRIABLE <br />ASBESTOS <br />SIGNATUR OF AUPqORIZED AGENT <br />DAT <br />❑ O <br />� n <br />\\l <br />fflLE <br />L <br />SCHEDULING MUST BE MADE PRIOR TO 3:00 Qf(A.THE DAY PRIOR TO EXPECTED ARRIVAL • ANY UNSCHEDULED LOADS ARE SUBJECT <br />TO REFUSAL UPON ARRIVAL. ONGOING IIIAILY DELIVERIES MUST BE SCHEDULED WITH THE LANDFILL THE DAY BEFORE. <br />Rev 11/09 NS -024 - GENERATOR COPY MANIFEST # I ftn llf na <br />