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Non-Hazardous Waste Manifest <br /> GENERATOR SECTION <br /> Non-Hazardous Waste Manifest Generator ID Number Waste Pronle Number Waste Tracking(Manifest)Number <br /> PH-22-502 BH 1043 1-2 <br /> Customer Billing Name and Mailing Generator's Site Address <br /> ANCON ProPacific Fresh:1-5 North at Exit 490 <br /> 570 Business Park Drive,Suite 110,Lincoln,CA 95648 Lodi,CA 95242 <br /> Customer Billing Phone: (916)917-6328 Generators Phone: (530) 893-0596 <br /> Transporter 1 Company Name US EPA ID Number <br /> ANCON CAD980737068 <br /> Transporter 2 Company Name US EPA ID Number <br /> Designated Facility Name and Site Address US EPA ID Number <br /> Potrero Hills Landfill, Inc. <br /> 3675 Potrero Hills Lane,Suisun,CA 94585 <br /> Facility's Phone: (707)432-4627 <br /> Containers <br /> Waste Shipping Name and Descrlption Total Quantity Unit Wit/Vol. Disposal Method <br /> No. Type <br /> 1 Non-Hazardous Soil 1 CM 20 Y ADC <br /> 2 <br /> 3 <br /> 4 <br /> Special Handling Instructions and Additional Information 24 Hour Emergency Response Phone <br /> Wear appropriate PPE when handling. Job#400-13-38502 B00-556-9090 <br /> B 1'91, 0- f G 2 <br /> 77-k r—k r P5 _ Emergency Response Guide Number <br /> GENERATOR'S/OFFEROR'S CERTIFICATION:I hereby certify that the above-described materials are non-hazardous wastes as dented by 40 CFR 261 or any applicable stale law. Further,that the above named <br /> materials are properly classified,described,packaged,marked and labeled,and are In proper condition for transportation according to the applicable regulations of the Department of Transportation. <br /> Generator's Offeror's Printed/Typed Name Signature Month Day Year <br /> tT�rray agnea q Rtger C ne <br /> Roger Chesshire on behalf of ProPacific Fresh Roger Chipe,•;p22pa t4agMH-0,� June 14 2022 <br /> TRANSPORTER • <br /> Transporter's Acknowledgement of Receipt of Materials <br /> Transporter 1 Printed/Ty d Name .5 , Signature Month Day Year <br /> 5 .q�-- <br /> Transporter 2 Printed/Typed Name Signature Month Day Year <br /> DESIGNATED FACILITY SECTION <br /> Discrepancy <br /> Discrepancy Indication Space 0 Quantity ❑ Type O Residue 7 Pggial Rejection ] Full Rejection <br /> ra <br /> Q/y� <br /> Alternate Facility(or Generator) -1 P'CCA I N•ytzlbLdffllI n C <br /> Facility's Phone: �g <br /> Signature of Alternate Facility(or Generator) Month 't-1 5 CO22 Year <br /> !1 c7 �.t <br /> Designated Facility Owner or Operator:Certification of Receipt of materials covered by the manifest except as noted In Discrepancy section <br /> Printed/Typed Name Signature Month Dom I <br /> PP9 o R i v a S Year <br />