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am' - SAVE OF Z& — TY SV ,�y�t�.- �•�t _ t'. <br /> Non-Hazardous Soils <br /> Date of Shipmenh Responsible for Payment•. Transport Truck#: Facility#: Approval Number. Load# <br /> A07 �7 a b R <br /> Generator'.Name and Billing Address: Generator's Phone#: <br /> �t CONOCOPHILLIPS RM &R1$- $8-789@ <br /> r=;l Person to Contact <br /> 16¢ROADWAY Shelby Lathrop <br /> 8ACkAMENTO, CA 95818FAx#: CustomerAccount umber <br /> Co'nsultant's Name and Billing Address: Consultant's Phone#: <br /> 7H Person to Contact <br /> r. V <br /> qFAX#: Custoater•Account Number r. <br /> Generation Site(Transport from):(name&address) Site Phone#: <br /> CONOCOPHILLIPS OI 1106 <br /> Person to Contact <br /> y 18500 S. HARLAN RD. € <br /> LA`fHROP, CA 96330 FAX#; <br /> y U Designated Facility g1ransport to):(nmat&address) Facility Phone#: # <br /> a 5011, SAFE 800 862-8001 <br /> � Person to Con <br /> 12328 HIBISCUS AVENUE OELLENA JEFFREY <br /> ADELANTO,CA 92301 FAX#: <br /> 780 246-8004 <br /> Transporter.Name and Mailing Address: Transporter's Phone#: <br /> BELSHIRE <br /> 849-080-6200 CARD00183913 <br /> . Person to Contact <br /> 26971 TOWNE CENTRE DRIVE <br /> LARRY MOOTHARI' 450847 <br /> FOOTHILL RANCH, CA 92810 <br /> FAX#: Customer Account Number <br /> 5 8E81: 192259 949-460-6210 ' <br /> Description of Soll Moisture Content Contaminated by: Approx,Qty: Description of Delivery Gross Weight Tbre Weight Net Weight <br /> t Sand❑ Organic❑ 0-10% ❑ Gas ❑ z <br /> Clay❑ Other ❑ 10-20% ❑ Oteseier <br /> ❑ �� �, 7 (l�fl, // 1 <br /> 20%-over ❑ Other ��IIII tP D <br /> Sand❑ Organic❑ 0-10% ❑ Ges E3 <br /> y 10-20% ❑ Diesel (3 <br /> ` M ❑ Other ❑ 20%-over ❑ Other ❑ t 1 <br /> List any exceptlon to items listed above: Scale Ticket# <br /> Generator's andfor consultant's certification:I/We certify that the soil referenced herein is taken entirely from those soils descried in the Soil Data ' <br /> Sheet completed and certified by melus for the Generation Site shown above and nothing has been added or done to such soil that would alter it <br /> in any way. <br /> r <br /> Print or Type Narne: Generator ❑ Consultant ❑ Signature and date: Month,.Da Year. <br /> Transporter's certification:I/We acknowledge receipt of the soil referenced above and certify that such soil is being delivered in exactly the same <br /> .. <br /> r condition as when received.I/We further certify that the soil is being directly transported from the Generation Site to the Designated Facility ��i <br /> without off-loading,adding to,subtracting from or in any way delaying delivery to such sit ys <br /> ' Print or ame: Sign Zd d MonthDa Year <br /> Discrepancijjes: x . <br /> l liCt� k <br /> Recycling Facility certifies the receipt of the soil covered by this manife t except as noted above: <br /> { : <br /> tor Type Name: Si d date: <br /> _- 0. JEFFREY/J. PROVANSAL <br /> Z1- <br /> `R t-.vim-�- <br /> TRANSPORTER COPY <br />