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I NON-HAZARDOUS WASTE SOLID (SOIL) <br />Port of entry/exit: <br />Date leaving U.S.: <br />111 Export from U.S. <br />Month Day Year <br />1001 c9 41 <br />Month Day Year <br />0 Type D Resdue <br />Manifest Reference Number <br />GENERATOR'S/OFFEFIOR'S CERTIFICATION: thereby declare that the contents of <br />marked and labeled/placarded, and are in all respects in proper condition for transport <br />this consignment are' Ily and accurately described above by the proper shipping name, and are classified, packaged, <br />according to appt e international and national governmental regulations. <br />17a, Discrepancy Indication Space 1-1 <br />L—I Quantity <br /> 1 <br />Month Day Year <br />I 10 (All i <br />(al.,) <br />‘t..c1 4,1( <br />15, International Shipments E Import to US. <br />Transporter Si:mature ;for exports only: <br />Transporter Acknowledgment of Receipt of Materials <br />Transporter 1 Printed/Typed Name <br />\kJ S-e*- <br />Transporter 2 Printed/Typed Name <br />Generator's/Offerors Printed/Typedr r <br />17b. Alternate Facility (or Generator) <br />Facility's Phone: <br />17c, Signature of Alternate Facility (or Generator) <br />Discrepancy <br />El Partial Rejection Full Rejection <br />U.S. EPA ID Number <br />Month Day Year <br />ipt of materials covered by the manifest except as noted in Item 17a <br />Signature <br />( <br />-1-8, Designated Facility Owner or Operator: Certification of <br />Printed/Typed Name <br />169-BLC-0 5 11977 (Rev. 9/09) DESIGNATED FACILITY TO GENERATOR <br />NON-HAZARDOUS <br /> 1 Generator ID Number <br />WASTE MANIFEST <br />Generator's Name and Mailing Address <br />VSS INTERNATIONAL, INC <br />3785 CHANNEL DR <br />WEST SACRAMENTO CA 95691 <br />Generators Phone: 916 373-1500 <br />Transporter 1 Company Name <br />FREMOUW ENVIRONMENTAL SERVICES INC <br />Transporter 2 Company Name <br />Desioncitidgirdae and Site Address__ <br />HILLS LAFILL, INC. <br />3675 POTRERO HILLS LANE <br />SUISUN CA 94585 <br />Facifir 's Phone: 707 432-4627 <br />Waste Shipping Name and Description <br />2. Page 1 of 3. Emergency Response Phone 4. Waste Tracking Number <br />1 800 424-9300 O-EMIREC <br />Generators Site Address (if different than mailing address) <br />VSS INTERNATIONAL, INC <br />WESTLINE RD & SOUTH MACARTHUR RD <br />TRACYCA 95276 <br />U.S.EPA ID Number <br />CAR000171017 <br />U.S. EPA ID Number <br />U.S. EPA ID Number <br /> <br />10. Containers '11. Total 12, Unit <br />No Type <br /> Quantity Wt Nol. <br /> <br />1 2 <br /> GENERATOR DESIGNATED FACILITY Special Handling Instructions and Additional Information i)PHLF-21-515 - Non-Haz Soil Exp. 6/18/22 Analytical Provided for Approval