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TPS Technologies Soil Recyc` ,Ig <br /> Non-Hazardous Soils <br /> Date of Shipment: Responsible for Payment: Transporter Truck#: Facility#: Given by TPS: Load# <br /> Responsible <br /> I I A04 00641 0021 <br /> Generator's Name and Billing Address: Generator's Phone#: Generator's US EPA ID No. <br /> Arco Products Co. 299 8691 <br /> Person to <br /> P. O. Box 5077 ontact: <br /> A SUPPle. Customer Account Number with TPS: <br /> Buena Park CA 90622 USSR QC11n ' <br /> Consultant's Name and Billing Address: Consultant's Phone#: <br /> Pinnacle Environmental Solutions <br /> 2201 BroadwayPerson to Contact: <br /> Suite 101 FAX#: Customer Account Number with ITS: <br /> Oakland CA 94612 USA (511) W-RUR <br /> Generation Site(Transport from): (name&address) Site—Kone one#: BTEX <br /> Levels <br /> Arco #06080 PWWtd ontec -8 8 9 1 TPH <br /> 85 Louise Ave. Levels <br /> Supple <br /> AVG. <br /> CLevels <br /> Vesignate a AI( ransport to): n to&address) ne W. - -8 8 7 2 Facilitv Permit Numbers <br /> TPS TECHNOLOGIES INC. eAR'.?A act: <br /> 20 Recycling Line <br /> 0 <br /> � Transporter ams Ind Mailing A dress , Transporter's Phone#: Transporter's US EPA ID No.: <br /> Dillard Environmental <br /> Person to Conta <br /> P. O. Box 579 ct: Transporter's DOT No.: <br /> #: Customer Account Number with TPS: <br /> Byron. CA 94514 USA 1 (925) 634-0569 1002780 <br /> Description of Soil Moisture Content Contaminated by: Approx.Qty: Description of Delivery Gross Weight Tare Weight Net Weight <br /> Sand ❑ Organic❑ 0-10% ❑ Gas ❑ <br /> Clay O Other ❑ 10-20% .❑ Diesel Ll <br /> 20%-over.❑ Other ❑ t/l <br /> f <br /> Sand ❑ Organic❑ 0-10% LlGas ❑ <br /> Clay ❑ Other ❑ 10-20% ❑ Diesel ❑ <br /> 20%-over❑ Other ❑ <br /> List any exception to items listed above: <br /> t 4 <br /> Generator's and/or consultant's certification: I/We certify that the soil referenced herein is taken entirely from those soils de ibed in the Soil D <br /> Sheet completed and certified by me/us for the Generation Site shown above and nothing has been added or done to such soil th =ftt7fner it in <br /> any way. <br /> a <br /> Print or Type Name: Generator ❑ Consultant ❑ Signature and date: Month Day Year <br /> Transporter's certification: I/We acknowledge receipt of the soil described above and certify that such soil is being delivered in exactly the same "t4 <br /> ocondition as when received. I/We further certify that this soil is being directly transported from the Generation Site to the Designated Facility <br /> a w�bout off-loading,adding to,subtracting from or in any way delaying A,livery to such site. tbi <br /> i <br /> t or T e•Vame: <br /> S re_agdate: Month Day Year <br /> Di crepancies: <br /> � I <br /> C Recycling Facility certifies the receipt of the soil covered by this manifest except as noted above: <br /> Print or Type Name: Signatureand date:cc <br /> Yint 4 <br /> k .;�t•_ ,m.a tat, �� x' � ._ � x <br />