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• r "IS Technologies Soil Recyct lm Non-Hazardous Soils Date of Shipment: ReI sponsible for Payment: Transporter Truck#: Facitity,V: Given by rps: /� . -r.-. ^� !-fel 1. Generator's Name and Boling Address: Generator's Phone#: Generator's US FPA lD No. i'`t t •1 Person to Contact- FAX;! ontactFAX;! Customer Account Number with TPS: Consultant's.Name and Billing Address: Consultant's Phone#: r'- f L :1 r . i ! l- r .1 : Person to Contact: r FAX# Customer Account Number with TP5 Generation Site(Transport From): (nanre&nddress) Site Phone#: BTF_X - Levels r r Person to Contact: TPH C Levels FA C#: AVG. Levels C U Designated Facility(Transport to): honor&rtddressl Facility Phone#: Facility Permit Numbers Q6 Person to Clontact � `. _ ] - -- r.'. I%'�C -a C _ _ili:7 - i,i. •r�.-.it �—i r_'ry FARC#: N Q) Transporter Name and Mailing Address: Transporter's Phone#: Transporter's US EPA W No.: Pers og to Contact: Transporter's DOT No.: Customer Account Number with TPS: Description of Soil Moisture Content Contaminated by: Approx.Oty: Description of Delivery GrossWeighi Tare Weight Net Weight Sand ❑ Organic 7 0-10% ❑ Gas ❑ Clay ❑ Other , 10-20% ❑ Diesel :1 20%-over❑ Other ZI Sand ❑ Organic❑ 0-10% ❑ Gas ❑ Clay ❑ Other ❑ 10-20% ❑ Diesel ❑ 20%-over❑ Other ❑ List any exception to items listed above: eil 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 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 s any way. f Priv r Type[+! Generator Consultant Si ture and 6: !� y' - / Month Day Year Transporter's certification: I/We acknowledge receipt of the soil-described ove and cert!tpfliat Lch soil is being delivered in exactly the same '- ocondition as when received. I/We further certify that this soil is being directly transpor ed from the Generation Site to the Designated Facility is 6 without off-loading,adding to,subtracting from or in any way delaying delivery to such site. Print orType Name: Signature and date: Month Da Year F+ A2 g go n ` y Discrepancies: V Ot Recycling Facility certifies the receipt of the soil covered by this manifest except as noted above: 3 Print or Type Name: Signature and date: GE` E .i Z,'C0NSULT.-1?1T'S COPY