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Non-Hazardous Waste Manifest <br /> GENERATOR SECTION <br /> Non-Hazardous Waste Manifest I Generator ID Number Waste Profile Number Waste Tracking(Manifest)Number <br /> PH-22-502 BH1043 2-2 <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 p q <br /> Customer Billing Phone: (916)917-6328 Generator's Phone: (530) 093-0596 <br /> Transporter 1 Company Name US EPA ID Number <br /> ANCON CA0980737068 <br /> Transporter 2 Company Name US EPA to 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 Description Total Quantity Unit Wt/Vol Disposal Method <br /> No. Type <br /> 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 <br /> t PPE when handling. Job#400-13-38502 800-556-9090 <br /> 1-� •1 !(1 <br /> Emergency Response Guide Number <br /> 7'rcet !� 447=1S_S <br /> GENERATOR'S/OFFEROR'S CERTIFICATION:I hereby certify that the above-described materials are non-hazardous wastes as defined by 40 CFR 261 or any applicable state 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 /> Roger Chesshire on behalf of ProPaciftc Fresh Roger Chesshire°'"°r`"° '"°°" '"• <br /> 9 o,r mnoa+aa95a.+.-0rW June 14 2022 <br /> TRANSPORTERSECTION <br /> Transporter's Acknowledgement of Receipt of Materials <br /> Transporter 1 m;ed I Typed Na t Signature Month Day )� Year <br /> Transporter 2 Printed/Typed Name Signature Month Day Year <br /> DESIGNATED FACILITY SECTION <br /> Discrepancy <br /> Discrepancy Indication Space O Quantity ❑ Type O Residue 7 Partial Re)ectlon /� ] Full Refection <br /> Alternate Facility(or Generator) �EPAri+D,N////���umher <br /> Facility's Phone: ✓lf�� `,�`��� <br /> Signature of Alternate Facility(or Generator) fid �{;� ay Year <br /> v J( <br /> Designated Facility Owner or Operator:Certification of Receipt of materials covered by the manifest except as noted In Discrepancy sectlonp �Y <br /> Q <br /> Printed/Typed Name Signature Month r/,, Day Year <br /> S <br />