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Technologies Soil Recycling <br /> )Yon-Hazardous Soils <br /> Date of Shipment; Responsible for Payment: Transporter Truck#: Facility#: Given by TPS: Load# <br /> Generator's Name and Billing.address: Ceneuator's Phone#: Generator's US EPA ID No. r. <br /> ?.' :i <br /> Person to Contact: .' <br /> a F,\X#: Customer Account Number with <br /> TPS: <br /> tf <br /> Consultant's Name and Billing Address: Consultant's Phone#: <br /> Person to Contact: <br /> FAX#: customer AC Count Number with TPS: <br /> Generation Site(Transport from): iirrmre&nddres_1 Site Phone#: 6TEX <br /> Levels <br /> + r Person to Contact- TPH <br /> C Levels <br /> F X#: AVG. <br /> to Levels <br /> l_.`. <br /> UDesignated Facility(Transport to,; (tranze&nddress) Facility Phone#: Facility Permit Numbers <br /> Person to MContact: <br /> L <br /> FAM: <br /> lb Transporter Name and Mading Address: Transporter's Phone#: Transporter's US EPA ID No.: <br /> : Ile";rte1 <br /> Person Contact: Transporter's DOT No.: <br /> FAX#: .t Customer ACCDunt Number with TPS: <br /> Description of Sal Moisture Content Contaminated by: Approx.Qty: Description of Delivery Gross Weight Tare Weight Nei Weight '`^' <br /> Sand ❑ Organic❑ 0-10% ❑ Gas ❑ < <br /> 10-20% ❑ Diesel ❑ <br /> Clay ❑ Other ❑ 20%-oyer❑ Other ❑ <br /> A Sand ❑ Organic❑ 0-10% ❑ Gas ❑ <br /> Clay ❑ Olher ❑ 10 -20% ❑ Diesel El <br /> O,o over❑ Other ❑ <br /> y, List any exception to items listed above: <br /> Generator's and/or consultant's certification: 1/We certify that the soil referenced herein is taken entirely from those soils described in the Soil Data <br /> Sheet completed and certified by melts for the Generation Site shown above and nothing has been added or done to srich soil that would alter it in <br /> any way. <br /> 7in'or Type Name: r� Generato/ ❑ Consultant R Signature an ate: l Month bay Year <br /> 2Z _ <br /> `m Transporter's certification: IIWe acknowledge receipt of the soil-desert ed-above and certify iha such soil is being delivered in exactly the same <br /> ocondition as when received. I/We further certify that this soil is being directly transported from the Generation Site to the Designated Facility <br /> H without off-loading,adding to,subtracting from or in any way delaying delivery to such site. <br /> roPrint! T�yp%Name: / Signature and date: Month Day year <br /> Discrepancies: - <br /> r <br /> u <br /> g <br /> Recycling Facility certiftes the receipt of the soil covered by this manifest except as noted above: <br /> ZZ <br /> V Print or Name <br /> �;. Type Signature and date: <br /> J <br /> 1 <br /> G ?,_3,ATO?,'CONSULF.ANT'S COPY <br />