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"S Technologies Soil Recycling <br /> Non-Hazardous Soils <br /> Date of Shipment: Responsible for ayment: Transporte Truck#: Facility#i Given by TPS: Load R <br /> 146 1 <br /> Generator's Mame and Billing.address: Gene_ratVr's Phone tl: _ Generator's US EPA ID No. <br /> - ! Person to Contact: <br /> F:\Xy. Customer Account Number with TPS: <br /> .' <br /> CO113ldtant's Name and Billing Address: Consultant's Phone#: <br /> iL <br /> ,1{.) i t�•.- .--.i m, t .- ..- L. Pa L 1: 4 Person to Contact: <br /> S. FAX' Customer Account Number with TPS: <br /> Generation Site(Transport from): f navre&nddress? Site Phone#: BTEX <br /> D.,±'•:S t'U t :,�s ! !.-_ --, i7.:] 1 . Levels <br /> ' +.'. -_ Person to Contact: TPH <br /> fi Levels <br /> w <br /> FAX;t: AVG. <br /> Levels <br /> l~ <br /> VDesignated Facility(Transport to): frame&address) Facility Phone#: Facility Permit Nrtmbers <br /> o �r � , V.1 _.._ . <br /> Clel F. _ `•_ L.L rl- s.Z3;i+� Person to Contact: <br /> ti <br /> .2 FAX#: <br /> V i•._i. _ rii•.. Il'_l. r...% _I..} 'U.t <br /> Gi <br /> QTransporter Name and Mailing Address: Transporter's Phone#: Transporter's US EPA 1D No.: <br /> Persor�to Contact. Transporter's DOT No.: <br /> FAX#: '—t -- Customer.Account Number with TPS: <br /> Desc ption of Soil Moisture Content Contaminated by: Approx.Qty: Description of Delivery Gross Weight Tare Weighl Net Weight <br /> r Sand ❑ Organic 7 0-10% ❑ Gas ❑ <br /> Cla ❑ Other 10-20% ❑ Diesel 0 <br /> y 20%-over❑ Other ❑ <br /> Sand ) Organic <br /> 0-10% ❑ Gas 13 <br /> Clay ❑ Other ❑ 10-20% ❑ Diesel ❑ <br /> 20%-over❑ Other ❑ <br /> List any exception to items listed abot-e: <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/us 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 /> Print 6r Type Name: Generator Consultant Sigiature a -date: - Month Day Year <br /> .121 <br /> i Transporter's certification: I/We acknowledge receipt of the coir rtescr �ed a ove and certifij that Stich soil is being delivered in exactly the same <br /> ccondition as when received. I/We further certify that this soil is being directly transported from the Generation Site to the Designated Facility <br /> r4 without off-loading,adding to,subtracting from or in any way delaying delivery to sash site. <br /> Prim or' pe Name: Signaturedate:' , l�. Month Day Yearim <br /> , <br /> ZZ <br /> Discrepancies: � <br /> Recycling Facility certifies the receipt of the soil covered by this manifest except as rioted above: <br /> Print or Type Name: Signature and date: <br /> GENERATOR, :ONSULTAt`t_"S C0 Py <br />