Laserfiche WebLink
�.,�.;.. 'S Technologies Soil Recycling <br /> Manifest Non-Hazardous Soils y an le # <br /> Date of Shipment: 7 hesponsible For Pay'nleni: Transportgr Truck N: Facility 0: Given by TPS: Load# <br /> UITn TML)r'ti`ami'and[tilling address: /f Generator',Phone#: Generator's LS EPA[a No. <br /> Person to Contact: <br /> FAX# Customcr.Account Number with TPS: <br /> Co+tiultant's Name and Billing,address Consultant's Phone#: <br /> Person to Contact. <br /> FAX#:f,. <br /> .1 c! Customer account Number with TP5: <br /> r <br /> Generation Site(Transport From l: fnatrte&addrrs>) Site Phone#: BTEX <br /> Levels <br /> r Person to Contact: TPH <br /> Levels <br /> FAX#: AVG, <br /> u a l i_ r'. t '._:•i-r' i ..!:, Levels <br /> UDesignated Facility(Transport tot: tname&address( FadlitN Phone it; Facility Permit Numbers <br /> t Person to Contact: <br /> J . + <br /> V <br /> F.aX#: <br /> mTransporter game and Mailing.address: Transporter's Phone#: Transporter's US EPA ID No.. <br /> Person�o Contact: Transporter's DOT No.: <br /> FAX#: ` Customer Account Number with TPS: <br /> r. <br /> Description of Soil Moisture Content Contaminated by: Approx.Qty: Description of Delivery Gross Weight Tare Weight Net Weight <br /> Sand O Organic] 0-10% ❑ Gas ❑ <br /> Clay ❑ Other O 10-20% C3Diesel ❑ <br /> 20%-over❑ Other ❑ <br /> Sand ❑ Organic 7 0-10% ❑ Gas ❑ <br /> Clay ❑ Other ❑ <br /> 10-20% ❑ Diesel ❑ <br /> 20°0-over❑ Other ❑ <br /> List any exception to items listed above: <br /> Generator's and/or consultant's Certh'cation: 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 /> any way. <br /> P,•',u"y,rof Type Name. Generator Consultant Si ld date: <br /> _ �ure� Month I Day I Year <br /> Transporter's certification: I/We acknowledge receipt of the soil discribed above and cert that such soil is being delivered in exactly the same <br /> Y. ro condition as when received. I/1Ne further certify that this soil is being directly transported from the Generation Site to the Designated Facility <br /> without off loading,adding to,subtracting from or in any way delaying delivery to such site. <br /> Print or Type Name: Signature and dat <br /> MontDay Year <br /> Discrepancies: <br /> V / <br /> Y / <br /> CRecycling Facility certifies the receipt of the sail covered by this manifest except as noted above: <br /> :i, Print or Type Name: Signature and date: <br /> PF ` <br /> GENEP.-\TO'-CONSULTANT'S COPY <br />