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LJ Keller Canyon <br />Sanitary Landfill <br />901 Bailey Road <br />Pittsburg, CA 94565 <br />Phone (925) 458-9800 <br />Fax (925) 458-9891 <br />U COftlrr l3uVos <br />Landfill <br />28972 Coffin Butte Road <br />Corvallis, OR 97330 <br />Phone (541) 745-2018 <br />Fax (541) 745-3826 <br />U Ox Mountain <br />Sanitary Landfill <br />12310 San Mateo Road <br />Half Moon Bay, CA 94019 <br />Phone (650) 726-1819 <br />Fax (650) 726-9103 <br />U New' Island <br />Sanitni'y 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 />Lif .rd <br />, waI <br />Landfill <br />9999 S. Austin Road <br />Manteca, CA 95336 <br />Phone (209) 982.4298:' <br />Fax (209) 982-1'009 <br />G E ATOR <br />WASTE ACCEPTANCE NO. <br />MAILING ADDRESS <br />1 f C <br />977 40 t~ <br />CITY, STATE; ZIP N <br />PERSONAL PROTECTIVE EQUIPMENT <br />GLICnJ y ..S.�.is" <br />PHONE <br />(REQUIRED <br />tf7 CLOVES ❑ GOGGLES ❑ RESPIRATOR 10 HARD HAT <br />t <br />O TY-VEK �6AFETY VEST <br />Cw %' <br />CONTACT PERSON <br />SPECIAL HANDLING PROCEDURES: <br />SIGNATURE OF AUTHORIZED AGENT / TITLE <br />DATE <br />2y- �. <br />GENERATORS CERTIRGAT1014: I hereby cedily that the above named material is d azerdous <br />waste as defined by 40 CFR Part 261 or I tle 22 of the Calgomla code of regulations, has been properly <br />described, classified and packaged, and Is in proper condition for transportation according to applicable <br />regulations; AND, If the waste is a meaiment residue of a previously restricted hazardous waste <br />subject to the Land Disposal Restdo low. I certify and warrant that the waste has been treated In <br />accordance with the requirements of 40 CFR Pad 268 and is no longer a hazardous waste as defined by <br />40 GFR Pad 261. <br />RECEIVING FACILITY .•; <br />-" <br />WASTE TYPE: <br />❑ DISPOSAL O SLUDGE <br />❑ CONSTRUCTION ❑ WOOD <br />• DEBRIS - _ ❑ OTHER <br />❑ SPECIAL WASTE <br />- <br />GENERATING FACILITY <br />TRANSPORTER - <br />NOTES: I VEHICLE LICENSE NUMBER <br />TRUCK NUMBER <br />is fa !Lr � csQ . S% <br />'i 7 -7 <br />ADDRE S <br />J <br />- <br />TY, STATE, ZIP • - <br />PH E' <br />END DUMP BOTTOM DUMP TRANSFER <br />'s <br />❑ ❑ .. ❑ <br />SIGNATURE OF.AUTHO IZED AGENT OR DRIVER <br />IDATE, <br />ROLL -OFFS FLAT-BED VAN DRUMS <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 />- <br />FACILITY TICKET NUMBER <br />❑ NON -FRIABLE <br />ASBESTOS <br />SIGNATURE OF HORIZED AGRq <br />DATE <br />O WOOD <br />❑ASH <br />O SPECIAL OTHER <br />SCHEDULING MUST BE MADE PRIOR TO 3:00 P.M.THE DAY PRIOR TO 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 />Rev 11/09 NS -024 GENERATOR COPY MANIFEST # 'I (I.n 7 1 n _ <br />