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Technologies Soil Recycling ' a Non-Hazardous Soils Date of Shipment: Responsible for Payment: Transporter Truck#: Facility.0 Given by.TPS: Load a < x' � O Y Genctator's Name and Billing-address: Generator's Phone#; - Generator's US EPA ID No. 1 k.: .:Rifat r i LI'._ . I -=' ! • - - )•1'k = Person to Contact. FAX#: Customer Account Number with TPS 1r Consultant's dame and Billing Address: Consultant's Phone#: # ' !. • _'i I I :.l i`_'Y.I L! , i Silk, Pelson t0 Con act: � `5 '-J'. '71FAX# y Customer AccouNumber umber with TPS: Generation Site(Transport from): (nnme t address) Site Phone#: BTEX i :t: Levels +. Person to Contact: TPH � Levels t4 FAX#: AVG. A Levels Designated Facility(Transport to): (unnfe£addressl Facility Phone#: Facilih Lim Permit bers U j. i, I L I I ,1✓1 b Person to Contact- L.ICl �. . ro f}. Ply,; :�!__.`i , !r, a fl, :I•_ .,� = :1 O FAX#: - `�° - t:_i Transporter Name and M[ ling Address: Transporter's Phone#: Transporter's US EPA ID No.- Person o.Contact: Transporter's DOT No.: =rr _ _ FAX#: — Customer Account Number with TPS: T 1 Descri Ion of Soil Moisture Content Contaminated by: Approx.Qty: Description of Delivery Gross Weight Tare Weight Net Weight Sand ❑ Organic] 0-10% ❑ Gas 0 Clay ❑ Other ❑ 10-20% ❑ Diesel 0 ti 20%-over❑ Other ❑ Sand C3 Organic Q0-10% Cl Gas ❑ _ Clay ❑ Other ❑ 10-20% ❑ Diesel ❑ 20%-over❑ Other ❑ List any exception to items listed above: .p. Generator's and/or consultant's certification: IlWe 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 s+:ch soil that would alter it in a' any way. ,.. Printer Type Name: Generator ❑ ' Consultant .� Si cure an da-te:' - .+7q. t f =y di- /1 r_� Month Day Year Transporter's certification: I/We acknowledge receipt of the soil described above and cert that-such soil is being delivered in exactly the same ccondition as when received. I/We fiirther certify that this soil is being directly transported from the Generation Site to the Designated Facility without off-loading,adding to,subtracting from or in any way delaying delivery to such site. C Print orName: ti Type Signature+/}nd date � Month Day ) Year /// Discrepancies: Ch Recycling Facility certifies the receipt of the soil covered by this manifest except as noted above: Print or Type Name: Signature and date. (Q11 r }s _I C__ Ic_.RATO;R,CONSULTANT'S COPY