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--S Technologies Soil Recyclinc Non-Hazardous Soils Date of Shipment: Responsible for Payment: Transporter Truck#: FaciT ; Givr n by 7 AS: Load M -. i ... i . Gener+r's Name and Billing A(dress: Generator's Phone : Generator's US EPA 10 No. �'F - Ll,_ i .Y =% �', I {; ; ;'�:• - :• I Person to Contact: Customer Account Number with TTS Consultant's Name and Billing Address: Consultant's Phone#: Person to Contact: i FAX#: Customer Account Number vvith TPS: i', L i?s: _ SL) l + _ 1 r is Generation Site jTransport Frorny (noun&address) Site Phone#: BTEX l�'. sLy•..:. ��L,-A I_ L .An #.; i Levels t rY lea r Person to Contact: TPH Levels 10 O FAX#: AVG. Levels C C] Designated Facihty,(Transport to): (soon&address( Facility Phone#: Facility Permit 1 uunbers ;cc IL .-s,y' Person to Contact: ti O FAX#: d. 4 'C' ':, 4 -,,) t..i:_ 1 'at4i ?:;i - 41. m Q) Transporter Name and Mailing Address: Transporter's Phone#: Transporter's GS EPA ID No.r /; Person t Contact: Transporter's DOT No.: FAX-9: l Customer Account Number with TPS: J t�• 1 i' �'- 1 /� `7 Description of Soil Moisture Content Contaminated by: Approx.Qty: Description of Delivery Gross Welght Tare Weight Net Weight Sand ❑ Organic 7 0-10% ❑ Gas ❑ Clav ❑ Other ❑ 10-20% ❑ Diesel ❑ 20%-over❑ Other ❑ Sand ❑ Organic 3 0-10% ❑ Gas U10-20% Clay ❑ other ❑ 10-20% ❑ Diesel ❑ 20%-over❑ Other ❑ List any exception to items listed above: ,s 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. - Print r Type Name:` Generator ❑ Consultant a7• Signature and dafe: J �+�s,.. Month lay Year L Transporter's certification: I/We acknowledge receipt of the soi -descftbed above and certify that ilich soil is being delivered in exactly the same m ccondition as when received. I/We further 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 ite. Print or Type Name: Signaturn_�ttd' Man Da Year Discrepancies: LL to C Recycling Facility certifies the receipt of the soil covered by this manifest except as noted above: •V Print or Type Name: Signature and date: GcNS;ZA„p!Z;'COiiSULT.a. .T'S COPY