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. r TPST Su,, _,yders of CA Non-Hazardous Soils Date of Shipment: Responsible for Payment: Transporter Truck#: Facility#: Given by PST: Load It AD7 Generator's Name and Billing Address: Generator's Phone#: Generator's US EPA ID No. 7-ELEVEN, INC. 049 4E0-92D0 P.O. BOX 84741 Person to Contact RANCHO SANTA MARGARITA, CA 92988 FAX#: Customer Account Number with TPST: Consultant's Name and Billing Address Consultant's Phone#: Person to Contact: FAX#: Customer Account Number with TPST: Generafion Site(Transport from): (name&address) Site Phone# BTEX 7-ELEVEN 14113 Levels .91340 WEST BENJAMIN HOLT DRIVE Person to Contact TPH Levels STOCKTON, CA j - FAX#: AVG. GLevels U Designated Facility(Transport to): (name&address) Facility Phone#: Facility Permit Numbers -8001 TPST SOIL REC(!Y� CLERS OF CAUFORNIq (moo�2act: C 12328 HIBISCUS AVENUE Person to Contact: m DELLENA.JEFFREY o ADELANTO. CA 92301 nx#: q) UeD)249-8DD4 c Transporter Name and Mailing Address: Transporter's Phone#: Transporter's US EPA ID No.: BELSHiRE (940)400-9200 CAROW183913 28971 TOWNE CENTRE DRIVE Person to Contact Transporters DOT No, FOOTHILL RANCH, CA 92910 LARRY MOOTHART 490947 BESI: 194837 FAX#: Customer Account Number with TPST: (840)490-5210 Description of Soil Moisture Content Contaminated by: Approx.Qty: Description of Delivery Gross Weight Tare Weight Net Weight Sand ❑ - orgarkU 0-10`/0 ❑ Gas ❑ Olay ,❑ other ❑ over - 10 ❑ Diesel 'J _ t[ 20%-over❑ Other ❑ — `f- Sand ❑ Organic❑ 0-10% ❑ Gas ❑ Cla O 10-20%. Ll Diesel y Other ❑ 20%-over❑ Other ❑ +�J List any 2icepfion to items listed above: ti le'tm Rets 1 Generator's and/or consultant's certification:.IlWe certify that the soil referenced ein is taken entirely from those soils described in the Soil Data Sheet completed and certified by me/us for the Generation Site shown abovea not ting has been added or done to such soil that would alter it in any way. Print or Type Name. Generator ❑ Consultant ❑ Signa and te: Month Day Year Larry Moothart of BEST an behalf of generator `m Transporter's certification: I/We acknowledge receipt of the soilldescri ed above and certify that such soil is being delivered in exactly the same ocondition as when received. I(We further certify that this soil is being directly transported from the Generation Site to the Designated Facility w without off-loading,adding to,subtracting from or in any way delaying delivery to such site. Pdnt ne Type NameSignature and �r Month Day Year Discrepancies: .0 kT 0 F Recycling Facility certifies the receipt of the soil mzuvei by this manifest except as noted abase: j, Printor Type Name: Signtyn•and dal• ' - -------- -_-- _— ys D. EFFREY/J. PROVANSAL Please print or type. i 1 GEN ERATOPJCONSULTANTS COPY