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"OS Technologies Soil Recyclinc* <br /> Manifest Non-Hazardous Soils <br /> Date of Shipment: Rtstonsible Forr'iynwnt: Transporter Trufk#: Faciljt #; Given v TU: <br /> ;> Y. �. Load# <br /> G4 •�a or's Namr and Bilin \ddress' Generitvr';Phone k: Generator's CS EPA ID No. <br /> Person to Contact: <br /> Customer Account..NumberLeith TP5: <br /> CcµV-oltant's Name and BilliaL-address: Consultant's PhoiIeV i <br /> Person to Contact, , <br /> A F.at#: Custo er <br /> i Tn +?i4qunt Number with TPS: <br /> Generation Site(Transport from o: i mime t address) Site Phone#: BTFX j <br /> r -c.:3:_.3 r :_>>_... ¢'_k l;d Levels I <br /> i <br /> 14.. :d'- r.l i. a•. Person to Contact: TPH <br /> C Levels ! <br /> efl i <br /> FAX#: AVG. <br /> CLevels <br /> VDesffii�gnated Facility(Transport to): (frame&address) Fatiliw Phone#: _ _ , Facility Permit Numbers <br /> O � <br /> i <br /> 2 _ - 1 <br /> (U <br /> yTransporter Name and(nailing Address: Transporter's Phone#: Transporter's US FPA ID No.: <br /> Persoryto Contact: Transporters DOT No.. ; <br /> _ �� +� � r,7 E -- � I .�.L; ,r' mss•/i7 /"�'� f <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 ❑ Organic❑ 0-10% Q Gas ❑ <br /> Clay ❑ Other > <br /> 10-20% ❑ Diesel ❑ ' <br /> 20%-over❑ Other ❑ <br /> Sand ❑ Organic ZI 1 0-10% ❑ Gas Q <br /> Clay ❑ Other ,, 10-20% <br /> 0-20% Z-3Diesel ❑ <br /> 0".-over❑ Other ❑ <br /> Gist any exception to items listed above- <br /> t <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 /> f <br /> Print Type Name: Gerreraror , / Consultant )i( Signature an ate: - Month I Dav Year <br /> Transporter's certification: I/We acknowledge receipt of the soil-deserilfed above and certify that such 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 /> y withotit off-loading,adding to,subtracting from or in any way delaying delivery to such site. 4 <br /> Type Name: Si lure and date: - <br /> � >� Month Day Year <br /> Discrepancies: - <br /> 'f- •V .d <br /> s Q Recycling Facility cerlfs the receipt of the soil covered by manifest except as noted above: <br /> J <br /> �f• V Print or Type Name: Signature and date: <br /> a <br /> Ppr[ri1 <br /> .T'S COPY <br />