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a SOIL SAM O;F cA - ThST Non-Hazardous Soils ' fVl�r1!IfeSt +� i Date of Shipment: Responsible for Payment: Transport Tr.¢rck#: Facility#. Approval Number: Load# Generators Name and Billing Address: Generator's Phone#: 7-EL.ES,,` I E , INC. ;:sal ""i'%D92314C 57},+i ft ' Person to Contact: P-0, silt);;B; ti`i FAX#: Customer Account Number Consultant's Name and Billing Address: Consultant's Phone#: Person to Contact: FAX#: Customer Account Number "S Generation Site(Transport from):(naarc&address) Site Phone-43 #: 7-ELE4`EN 14117 ;}itCt-CD3-'111'34? 176 COUNTRY CLUB r�Ll/Ir+ Person to Contact: .m. �7YOC;;UC1itif. :f: 0e. j FAX#: J C £l O - {1 Designated Facility(Transport to):(name&address) Facility Phone#: -_ (800)862-8001 a � _ C r, 1 ;_.�_. r.,.t Person to Contact: i ro 1292 r!41Ei.�,,:tJ.., kliErd€.;': JOE 'f2= }/?N .L. ro FAx#: _ - c (700) 61-180(1111 vi � Transporter Name and Mailing Address: Transporter s Phone#: ; (PJ31•a0r_:_62(.JD i--AR000-183P1S _ BEL_% lr=lE j 25971 f ti?N1V1" (-'ENTRE DR- I'VE Person to Contact: ✓af]TI iSI,.L, I :�.(S( I-1. ("A�1 .i7'it1 l..lk�?F�1' rvfC)�a;f vat cl -1506-47 M' FAX#: Customer Account Number 9ESI� 248148 Description of Soil Moisture Content Contaminated by: Approx.Qty: Description of Delivery Gross Weight Tare Weight Net Weight Sand El Organic U g0 120% ❑ Daesel El01-w 20%-over U Other U Clay❑ Other U l!'; Sand UOrganic❑ 0-10% ❑ Gas ❑ i,)L, L Clay❑ Other ➢ 10-20% ❑ Diesel ❑ 20%-over ❑ Other U ( C List any exception to items listed above: Scale Ticket# Generator's and/or consultant's certification:I/We certlfij that the soil referenced herein is taken entirely from those soils descried in the Soil Data i Sheet completed and certified by me/us for the Generation Site shown above and nofhing lata been added or done to such soil that would alter it i IoNe in any way. i. jj Print or Type Name: Generator U Consultant ❑ Signature and da Month Day Year i.arr{:rVr,ptt't::tr4 of E4---,S1 t7ri br,•.i1a.f of t.prit-t-iator . I `a Transporter's certification:I/We acknowledge receipt of the soil referenced above and certify that such soil is being delivered in exactly the Baine o condition as when received. We further certify that the soil is being directly transported from the Generation Site to the Designated Facilihj I/ y without off-loading,adding to,subtracting from or in any way delaying delivery to such site. _ i dPrint or Type Name: SignetuV dater Month Day Year _ Discrepancies: LLtm II Recycling Facility certifies the receipt of the soil covered by this manifest except as noted abo e o - atnre and date-.....- _.... - - ------ - ---- -------- -- — - v ------------- Sign '0 Vilfl SP U.r — Please piiDt 31 1� 1 4f T'R COM - -