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-"'S Technologies Soil Recycling , <br /> M1Il1 eSt Non-Hazardous Soils <br /> Date of Shipment: Responsible for lravment: Transporter Truck C Facility#: Given by TPS: Load 4 <br /> Grnrr.ltor's Name and Billing Address: ` <br /> Genertator's Phone M: Generator's Lti EPA ID No. <br /> Person to Contact: <br /> Customer Account dumber with TI 5: <br /> Consultant's Name and Billing dares;: Consultant's Phone#: <br /> L <br /> Person to Ca <br /> i. ) t -i Contact: <br /> ci At <br /> FAX-.Y: Customer Account Number with TPS: <br /> Generation Site(Transport from): 'name iS ercidress) Site Phone#: ETEX <br /> ' - .. :�r t,'�' -:. i i t` L.� Levels <br /> Person to Contact: TPH <br /> Levels <br /> � FaX#: AVG. <br /> C <br /> VDesignated Facility(Transport tor: (,ranee&nddressi Facility Phone#: Facility Permit Numbers <br /> Person to Contact: <br /> tG :-'. <br /> O <br /> F.aX -71 <br /> #: <br /> 41 - <br /> C <br /> Trnt)S lnrter Nan;w an Nlailinn address: Transporter's Phone#: Transporter's US EPA[D No.: <br /> L'J� lA <br /> f � <br /> Person to Contact: Transporter's DOT No.: <br /> r r <br /> f:�>;:, f ;l, •. � (,til �J� <br /> FAX#: Customer Account Number with TPS: <br /> 1 <br /> Description of Soil Moisture Content Contaminated by: Approx.City: Description of Delivery Gross Weight Tare Weight Net Weight l <br /> Sand ❑ Organic❑ 0-10% ❑ Gas ❑ <br /> 10-20% Q Diesel ❑ <br /> Clay Other O 20%_over❑ Other ❑ ; <br /> I <br /> Sand :1 Organic❑ 0-10% ❑ Gas ❑ i <br /> Clay ] Other ❑ 10-20% C3Diesel ❑ <br /> 20%-over❑ Other ❑ I <br /> List any exception ro items listed abo%-e: f <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/tis 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 /> Prin/or type Nam. �_ Generator 7 Consultant Signature and ate: r Month I Day I Year <br /> Transporter's certification: I/We acknowledge receipt of the sof(descra"bed above and terry that such soil is being delivered in exactly the sante <br /> condition as when received. I/We fiirther 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 Name: <br /> tq � Signature and date: Month Day. Year <br /> ti <br /> Discrepancies: <br /> _ •v <br /> o� <br /> Recycling Facility certifies the receipt of the soil covered by this manifest except as noted above: <br /> Print or Type Name: Signature and date: <br /> Plsess P 7_r ,F r'i <br /> GENEZA-QR, CO 1,i5ULTAN T S COFY <br />