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*� —QS Technologies Soil Recycline <br /> �YirO. Non-Hazardous Soils � <br /> Date of Shipment: Reseonsible,for�'ayment: Transporter Truck N: Facility.#: Given by TPS: Load# s <br /> 7 � r 1 <br /> General or's Name and Btlon-•Address' Generator']S(Phu Generator's LS EPA ID i\lo <br /> rl,.r tt? - - ne#:. Generar r <br /> Person to Contact: <br /> FAX#i. J CustuXrre}Account Number with TPS- <br /> Coneultartt's ti'ime and Billing_Address:, [ ConstdtanCs_Phone <br /> r <br /> i stil <br /> r Pe on to Contact: <br /> . . 1 f7 FA\II: - r <br /> customeir rrlccnttnt Number with TPS: <br /> j <br /> �i <br /> Generation Site(Transport from): rrartre&address) Site Phone#: RTEX <br /> Levels <br /> t., t. .. -_ .t.�rs .r t .. Person to Contact: TPH -. <br /> C Levels <br /> tC <br /> { ; F..AX#- AVG. <br /> " h _i . ._. r <br /> H Levels <br /> C <br /> (Q] Desio aled Facility(Transport tor-. ownre£+adeiress) Facilit_v.Phone#:,. Facility Permit Ntunbers <br /> L <br /> Z 1 " ;'t.; r t_a Person tolC�9 tir_ .1.. <br /> act <br /> Rl <br /> O <br /> � L-�i. =i'i ri3•::;^ .�. 'rt ='�`4f � ..;� F_I.X#i <br /> Z Transporter Name and:Mailing Address: Transporter's Phone#: Transporter's LS EPA 1D No.: <br /> jy <br /> -�� /�i���� !� r r t ��/ '� •,� Person to Contact: Transporter's DOT No.: <br /> FAX#: J Customer Account Number with TPS: <br /> Description of Soil Moisture Content Contaminated by: Approx.Qty: Description of Delivery Gross Weight Tare Weight Net Weight r <br /> Sand ❑ organic❑ 0-10% ❑ Gas ❑ <br /> Clay ❑ Other p10-20% ❑ Diesel ❑ <br /> 0°0-over❑ Other ❑ <br /> Sand ❑ Organic❑ 0-10% ❑ Gas ❑ r <br /> Clay ❑ other ❑ 10-20% ❑ Diesel ❑ r <br /> 0%-over❑ Other <br /> List any exception to items listed above: <br /> "e <br /> r r <br /> Generator's and/or consultant's certification: 1/We certify that the soil referenced herein is taken entirely from those soils described in the Soil Data 3 <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 /> .r Print Type Name: -�.enerator ❑ Consultant a r Signature an ate: /•7 �;' Month Day Year <br /> Transporters certification: 1/We acknowledge receipt of the soff4esfbed a ove and certify that such soil is being delivered in exactly the same <br /> ocondition as when received. I/We further certify that this soil is being directly transported from the Generation Site to the Designated Facility i <br /> ;t& H without off-loading,adding to,subtracting from or in any way delaying delivery to such site. i <br /> Print or Type Name: r` , / Sigiratureand dire: r Month Day Year ~� <br /> Discrepancies: <br /> V N <br /> Recycling Facility certifies the receipt of the soil covered by this rnantfest except as noted above: <br /> :l Print or Type Name: Signature and date: <br /> - 41 <br /> Gci ciJ�iCGtiSU_T��iT'S COPY <br />