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_-XS Technologies Soil Recycling <br /> r Non-Hazardous Soils <br /> Date of Shipment: Responsible for Payment: Transporter Truck N: Facility#: Given by TPS: Load N <br /> 1 <br /> Generatw's Name and Billing.address: Generator's Phone it: Generator's US EPA ID No. <br /> F.. <br /> Person to Contact: <br /> F-VX4: Customer Account Number with TPS: <br /> Consultant's Name and Billing Address: Consultant's Phone#: <br /> 1.it _ {. 1-cr. r_ -- Person to Contact- <br /> i ( FAY#: Customer Account Number with TPS: <br /> Generation Site(Transport from): [name&addrescY Site Phone#: BTEX <br /> f' ° "I�t 1:-:a '-. 1�•J I-.i Levels <br /> Person to Contact: TPH <br /> C Levels <br /> v <br /> � FAY#: AVG. - <br /> Levels <br /> VDesignated Facility(Transport to}: (name&addreso Facility Phone#: Facility Permit Numbers <br /> j . <br /> a <br /> Person to Contact: <br /> :1 i.i;'l L3i. f1 M 1i t=,I', i -it A , tt•' <br /> t4 - <br /> i FA K#: <br /> i _. rFdi•.i. <br /> Transporter Name and Mailing Address: Transporter's Phone#: Transporter's US EPA ID No.: <br /> Person to Contact: Transporter's DOT No.: <br /> FAXA Customer Account Number with TPS: <br /> Description of Soil Moisture Content Contaminated by: Approx.Oty: Description of Delivery Gross Weight TareWeight Net Weight <br /> Sand ❑ Organic 7 0-10% ❑ Gas ❑ <br /> Clay ❑ Other p 10-209/6 ❑ Diesel ❑ <br /> 20°a over❑ Other ❑ <br /> 4. Sand ❑ Organic 7 0-10% ❑ Gas ❑ <br /> Clay ❑ other ❑ 10-20% ❑ Diesel EI <br /> 20%-over❑ Other ❑ <br /> - List any exception to items listed above: <br /> £ Generator's and/or consultant's certification: I/We certify that the soil referenced herein is taken entirely from those soils described 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 in <br /> r <br /> any way. <br /> _h Print r Type Name: Generator Consultant ( Signa m and d r Month Day Year <br /> _7 <br /> Transporter's certification: I/We acknowledge receipt of the sot descllbe ab a and certify tha6u&h soil is being delivered in exactly the same <br /> C condition as when received. I/We further certify that this soil is being directly transported from the Generation Site to the Designated Facility <br /> y without off-loading,adding to,subtracting from or in any way delaying delivery,to such site. <br /> Print ori)ypeName: Signature ddate: ;' i Month Day Year , <br /> , fit_ <br /> S <br /> DlscrepanC6: <br /> (13ti <br /> C: Recycling Facility certifies the receipt of the soil covered by this manifest except as noted above. <br /> :b, Print or Type Name Signature and date <br /> C0� <br /> Gc;I. TO 0NSULIIA N'T'S C 0 P Y <br />