ARCHIVED REPORTS_XR0003558 - Laserfiche WebLink

Home Browse Search

Technologies Soil Recycling r Mani est Non-Hazardous Soils `j'''Manifest# y T Date of Shipment: ] Responsible for Payment: Transporter Truck#: Facility fl: Given by TPS: Load p Q:unerah,r's Nonw and Billing Address: Generator's Phone p: Generator's US EPA ID No. i i'!1 L t''a Person toCon tact: FAX;, Customer Account%umber with TPS: Consultant's game and Billing Address: Consultant's Phone# Person to Contact: i :i . :] - rii ;. L i F.AX# Customer_Account dumber with TP5: t - - _ i `.? i•�� _ _. ., ._ .''1�.=is 's .. .i Generation Site jracisport from): 0eame&ad=mess) Site Phone#: BTEX Levels k Person to Contact: TPH i, =�•.. � +i�:._[- I',�-�L. t..i e til z?i i_:i i i�- Levels c ` FAY#: AVG. A ' � "I t r i};_;-. Levels Cj.1 Designated Facility{Transport to}: fnanze&addrrs5) Facility Phone#: Facility Permit Vtunbers 'ir':1 Tf•_'�=:i-t;"�:�il._Ci�.��r.� IhE�1. c�� i.--";:.-�°_}.. -, . _f t- zfiC, Person to Contact: V O FAX#: to t;J r tit fr.A.ik 1, 1 .,5 -1 ;-�tC' � .� .:t ranlspo�rter Name and Mailing Address: Trans Orter's Phone#: Transporter's L'S EPA 1D No.: PerSL> to Contact Transporter's DOT No.: FAX Customer Account Number with TPS: Description of Soil Moisture Content Contaminated by: Approx.Qty: Description of Delivery Gross Weight Tareweight Net Weight Sand q Organic❑ 0-10% ❑ Gas ❑ Clav , Other 7 10-20% ❑ Diesel ❑ 20%-aver❑ Other ❑ ,and 7 Organic❑ 0-10% ❑ Gas ❑ Clay ❑ Other ❑ 10-20% U-20% ❑ Diesel ❑ 20%•over❑ Other ❑ List any exception to items listed above: Generator's and/or consultant's certification: I/We cert that the soil referenced herein is taken entirely frons those soils described in the Soil Data I 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. i l iJ Pring Type Naft Generalor Q Consultant _111� Sign to d date: ' 1 �� Month Day Year Transporter's certification: I/We acknowledge receipt of the silt described above and certify that such soil is being delivered in exactly the sante ocondition as when received, I/We further certify that this soil is being directly transported from the Generation Site to the Designated Facility y without off-loading,adding to,subtracting from or in any way delaying delivery to such site. ro Print or Type Name. Signature and date: '� gna Month pay Year - i Discrepancies; f C Recycling Facility certfes the receipt of the soil covered by this manifest except as noted above: VPrint or Type Name: Signature and date: Please` GE`iE��,T D.3, CON5U!TAT 5 COPY