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Technologies Soil Recycling <br /> Manifest Non-Hazardous Soils y .Illlienlfest# <br /> f�- <br /> Date of Shipment: Responsible for Payment: Trarsporier Truck#: Facility q: Given by TPS: Load 11 <br /> r / ) <br /> ikwil crater's.\ani•and Billing.>Lidre�,; Generator's Phone t: Generator's L'S EPA ID No. <br /> Person to Contact: <br /> 27 - <br /> .. l' 1:: _ <br /> FAX== Customer ASOImt Number with TPS: <br /> COIL LLltant'S Same and Billing Address: COnsuitant s Phone#' <br /> 6. <br /> Person to Contact: <br /> FAX#r Customer account dumber with TPS: <br /> Generation Site(Transport from): Inaonv&addresci Site Phone#: BTEX <br /> Levels <br /> _1 i �. ,_'1_ Person to Contact: TPI-( <br /> C <br /> r0 <br /> FAX#: AVG. <br /> h 1.i.r e.J 1 14J l Level= <br /> C <br /> VDesignated Facility{Transport to): 0jame&nddress} Facility Phone#: Facility Permit Numbers <br /> 1: '11 •_) <br /> -1:) s5�+ _1 !_fe•:y :, _ Person to Contact: <br /> ti <br /> O <br /> FAX#: <br /> c <br /> d Tninsporter Name and 1,laihng Address: Transporter's Phone#: Transporter's US EPA ID No.: <br /> C7 C" <br /> Persory to Contact: Transporter's DOT No.: <br /> 771 4T' 7' <br /> ? / FAX#: Customer Account Number with TPS: <br /> Description of Soil Moisture Content Contaminated by: Approx.Qty: Description of Delivery Gross Weight Tare Weight Net Weight <br /> Sand G Organic❑ 0-10% 7 Gas Q <br /> ❑ 10-20% ❑ Diesel 7 <br /> Clav Other > <br /> 20%-over❑ Other 7 <br /> Sand ❑ Organic❑ 0-10% ❑ Gas 7 <br /> Clay ❑ Other ❑ 10-20% ❑ Diesel ❑ <br /> 20%-over❑ Other ❑ <br /> List any exception to items listed above: <br /> f: <br /> 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 <br /> Sheet completed and certified by me/tis for the Generation Site shown above and nothing has been added or done to such soil that would alter it in <br /> any way. <br /> Prinr Type Name: Generator Consultant _. .�gnatum a dale: ,f Month Day Year <br /> �� <br /> J <br /> Transporter's certification: I/We acknowledge receipt of the soil described above and certify that such soil is being delivered in exactly the same <br /> condition as when received. I/We fiirther certify that this soil is being directly transported from the Generation Site to the Designated Facility <br /> -^ without off-loading,adding to,subtracting from or in any way delaying delivery to such site. <br /> Print Type Name: � / 5igmture and date: Month Day Year <br /> Discrepancies'. <br /> ,C Recycling Facility certifies the receipt of the soil covered by this manifest except as noted above: <br /> Print or Type Name: <br /> yp Si re and date: <br /> FIiaW <br /> _O.`iS'J!TANT'S COPY <br />