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��( —PS Technologies Soil Recyclinr <br /> `tYlaF i Non-Hazardous Soils , <br /> Date of Shipment: Respons_iblg for Payment: F <br /> ranspoderTruck 0: Facility,#q Given_by TPS: Load 0 <br /> - r I /.. <br /> Ggiccakor,'s and Biljing Address: Genr•Catnr'S Phone#: Generator's LS EPA[D No. <br /> Person to Contact: <br /> F_\X4: Customer account Number with TPS: ' <br /> CDS—ultant's Name and Bill4iaAddrzsa: Con ultant'&Phone <br /> Person to Conlicti . <br /> FAX <br /> Customer Accoumt Number with TPS: <br /> Generation Site(Transport_from): lnnwe&address) Site Phone : BTEX <br /> Levels <br /> Person to Contact: 1'I'Ff A <br /> y <br /> R Levels ti <br /> -t. FAX#: AVG. t: <br /> y Levels <br /> C <br /> VDesi mated Faciiih•(Transport to inanre&address) Facilihr PhoneT -1 #:: -. Facilitc Permit Numbers <br /> l Person to, onkac�y <br /> FAX#: <br /> Transporter Name and Mailing,address. Transporter's Phone#: Transporter's LS EPA ID No.: <br /> Person to Contact: Transporter's DOIIND.: <br /> FA i -� Customer Accounmber with TPS: <br /> 1 a f f <br /> Description of Soil Moisture Content Contaminated by: Approx.Qty: Description of Delivery Gross Weight Tare Weight Net Weight <br /> :z <br /> Sand ❑ Organic 7 0-10% ❑ Gas ❑ <br /> Clay 7 Other -J10-20% ❑ Diesel ❑ <br /> 2096-over❑ Other <br /> 0-10%-. <br /> Sand ❑ Organic 7 ❑ Gas ❑ '�- <br /> Clav 7 Other 0 10-20% ❑ Diesel 17 <br /> 20%-over❑ Other ❑ 333rrrr' <br /> List any exception to items listed above. <br /> Generator's and/or consultant's certification: !/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 /> Priv or Type Name;_ —Generator O Consultant Signature and dale:J /' Mo/nth Da <br /> Year a <br /> - -z. xY <br /> .� `�i-- F <br /> 3( <br /> L Transporter's certification: I/We acknowledge receipt of the soil describers a `e and certify that such soil is being delivered in exactly the same <br /> m <br /> condition as when received. I/We further certify that this soil is being directly transported from the Generation Site to the Designated Facility <br /> H without off-loading,adding to,subtracting from or in any way delaying delivery to such site. <br /> ` R Print or Type Name: Signature and date: Month Day Year <br /> z5 ! �y <br /> i <br /> Discrepancies: <br /> v <br /> ti <br /> CRecycling Facility certfts the receipt of the soil covered by this manifest except as noted above: <br /> t3 Print or Type Name: Signature and date: <br /> a <br /> S CO'Y <br />