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—"S Technologies Soil Recycling Non-Hazardous Soils Date of Shipment: Responsible for Paymenl: Transporter Truck#: Facility C Given by TPS: Load 0 f' JT _ - - / '1'F•ti - _ 1. -� �/ ( �) 1 Generator's Name and Billin Address: Generator's Phone#: Generator's US EPA 1D No. t 1[ .i. 1 , - .'- - '4�_ Person to Contact: f L ' i F•a?i# Customer account Number with TPS: Consultant's Name and Billing address: Consultant's Phone k: t :s!m""r' t' d t > Person to Contact. FA\#: Customer account Number with TPS: Generation Site(Transport from): fnaine&addresal Site Phone#:- BTEX Y' L ;r[t 'i]. i Levels } kI h'!:'� l'i c i_ 'r., (.i=,a a is I_.-i .t Person to Contact- 4111TPH r C Levels F.3)C4: AVG. Lei-els Cj Designated Facility(Transport to): fnowe&address) Facility Phone#: Fadlitc Permit Numbers , p T1`1 i C G 6? sit 2•,_y ' 1 i. c t_ i<<? Person to Contact: ipi]tjT l ii LP s L r O FAX#: RI 17' t eta• e�� Q.•St _I't� �1 L �F•.'a}f '��.1 •1 . : � } - .T d qJ Transporter Name and Mailing Address: Transporter's Phone#: Transporter's US EPA 1D No.: t Person to Contact: Transporter's DOT No.: -- 'fes ` 1'�y' � _' .��_ _ _ !. � •y i 1} FAX*: Customer.account Number with TPS: i Description of Soil Moisture Content Contaminated by: Approx.Oty: Description of Delivery Grass Weight Tare Weight Net Weight .; Sand ❑ Organic❑ 0-10% ❑ Gas ❑ . Clay Cl Other ❑ 10-20% ❑ Diesel ❑ 201-over❑ Other ❑ Sand ❑ Organic❑ 0-10% ❑ Gas ❑ Clay ❑ Other ❑ 10-20% ❑ Diesel 20%-over❑ Other ❑ 4. List any exception to items listed above: �d 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 any way, Type Name` ��.—Generator Consultant g' Signature and da tr.'' Month Day Year P7 or L. Transporter's certification: I/We acknowledge receipt of the soil described a e and certify that such soil is being delivered in exactly the same o' condition as when received. I/We further certify that this soil is being directly transported from the Generation Site to the Designated Facility - without offloading,adding to,subtracting from or in any way delaying delivery to such site. roPrint or Type Name: signature and date: Month Day Year - Z-44-6 OL �' r Dlscrepandes: as Recycling Facility certifies the receipt of the soil covered by this manifest except as noted above: -_ U Print or Type Name: Signature and date: Q COPY