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,r 'OIL SAFE O "LA — TPST y antfest* *� <br /> r <br /> M1X1lE'S " ✓ Non-Hazardous Soils <br /> Date of Shipment: Responsible for Payment: Transport Truck#: Facility#: Approval Number: Load# <br /> , <br /> Generators Name and Billing Address: Generator's Phone#: <br /> Person to Contact: <br /> FAX#! Customer Account Number <br /> Consultant's Name and Billing Address: Consultant's Phone#: <br /> Person to Contact: <br /> FAX#: Customer Account Number <br /> Generation Site(Transport from):(naiee&address) Site Phone#: <br /> Person to Contact: <br /> C <br /> FAX#: <br /> ` C <br /> V Designated Facility(Transport to):(name to address) Facility Phone#: 4 <br /> Person to Contact: <br /> FAX#: <br /> IMC <br /> d Transporter Name and Mailing Address: Transporters Phone#: <br /> ROY, <br /> Person to Contact: <br /> . ,tisi,•ti,^�•i' f„i��i�.Iii+'+tt j, z Jy t-,1'. <br /> t-r_. :,.T milt_`... R: '--' „ _ 2}di 0 <br /> FAX#: Customer Account Number <br /> r,01 -Q,,; ( i 2 10 <br /> Description of Soil Moisture Content Contaminated by: Approx.Qty: Description of Delivery Gross Weight Tare Weight Net Weight <br /> Sand❑ Organic❑ <br /> 0-10% El Gas ❑ <br /> 10-20% ❑ Diesel ❑ <br /> Clay ❑ Other ❑ <br /> 20%-over ❑ Other O <br /> Sand❑ Organic❑ 0-10% 13 Gas ❑ <br /> Clay ❑ Other ❑ 10-20% 13 Diesel ❑ <br /> `; l <br /> 20%-over Cl Other ❑ <br /> List any exception to items listed above: Scale Ticket# <br /> ir1•(/; <br /> Generator's and/or considtant'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 me/us 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 /> Print or Type Name: Generator ❑ Consultant ❑ Signature and date: Month Day Year <br /> ai'n %4 c?'.h nR fir Br' c;n `A, (lh.!r a ,'.en--?raf.,Sf <br /> Transporters certification:I/We acknowledge receipt of the soil referenced above and certifij that such soil is being delivered in exactly the same <br /> e condition as when received.I/We fiirther certifij that the soil is being directly transported from the Generation Site to the Designated Facility <br /> y without off-loading,adding to,subtracting fivin or in any way delaying delivery to such site. <br /> C Pt orType Namg i Signature.and-date:`” " T"•'w- — w •, Month Day Year <br /> 77 <br /> Discrepancies: <br /> V <br /> % <br /> ti <br /> ZT <br /> 9 Recycling Facility certifies the receipt of the soil covered by this manifest except as noted above: <br /> vPrint or Type Name: Signature Arid date: <br /> Me*print,or type. <br /> r.PN1FRATnP/r.nNI.q1 ItTAIVTC C.r)PY <br />