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Non-Hazardous Waste Manifest <br />Non-Hazardous Waste Manifest <br />GENERATOR <br />Generator ID Number <br />SECTION <br />Waste Profile Number <br />PH-22-789 <br />Waste Tracking (Manifest) Number <br />Bin: BH1012 <br />Customer Billing Name and Mailing <br />ANCON <br />570 Business Park Drive, Suite 110, Lincoln, CA 95648 <br />Customer Billing Phone: (916) 917-6326 <br />Generators Site Address <br />Fly Car Transport LLC <br />E Lafayette Street between S. Grant and Aurora Street S. Stockton, CA 95215 <br />Generator's Phone: 706-392-9742 <br />Transporter 1 Company Name <br />ANCON <br />US EPA ID Number <br />CAD980737068 <br />Transporter 2 Company Name US EPA ID Number <br />Designated Facility Name and Site Address <br />Potrero Hills Landfill, Inc. <br />3675 Potrero Hills Lane, Suisun, CA 94585 <br />Facility's Phone: (707) 432-4627 <br />US EPA ID Number <br />Containers <br />Total Quantity Unit Wt / Vol Disposal Method Waste Shipping Name and Description <br />No. Type <br />I Non-Hazardous Soil 1 CM 20 Y H131 <br />2 <br />3 <br />4 <br />Special Handling Instructions and Additional Information <br />Wear appropriate PPE when handling. Job # 400-13- 35(911--6 <br />24 Hour Emergency Response <br />800-556-9090 <br />Phone <br />Emergency Response Guide Number <br />GENERATOR'S / OFFEROR'S CERTIFICATION: I hereby certify that the above-described <br />materials are properly classified, described, packaged, marked and labeled, and are <br />materials are non-hazardous wastes as defined <br />in proper condition for transportation according la the <br />by 40 CPR 261 or any applicable state law. Further, that <br />applicable regulations of the Department of Transportation <br />the above named <br />Generator's Offeror's Printed / Typed Name <br />Roger Chesshire on behalf of Fly Car Transport <br />Signature <br />Roger Chesshire `D'argror:7417.0°Ztry <br />Month <br />Aug <br />Day <br />31 <br />Year <br />2022 <br />TRANSPORTER SECTION <br />Transporter's Acknowledgement of Receipt of Materials <br />Transporter 1 Printed / Typed Name <br />JAcoin DEmrSE-1 <br />Signature <br />... <br />Month et:01 Day 31 Year ...iz. <br />Transporter 2 Printed / Typed Name Signature ‘,...) Month Day Year <br />DESIGNATED FACILITY SECTION <br />I/ <br />Discrepancy <br />Or Hi/ •// <br />. / <br />Discrepancy Indication Space 0 Quantity ID Type CI Residue D Partial Rejection <br />f••• <br /> <br />0/)/00/fiii , <br />a Futl Reieclio,, , ; <br /> <br />. 0 e <br />Alternate Facility (or Generator) <br />AUG ? <br />w <br />Facility's Phone: 271)./ i <br />US EPA ID Number <br />/ <br />2022 i <br />Signature of Alternate Facility or Generator) <br />s"-t-'0/11,., z ., <br />Month <br />li (,t, • . <br />Year <br />ci / a c• <br />Designated Facility Owner or Operator: Certification of Receipt of materials covered by the manifest except as noted in Discrepancy section ° Q L1nd,,, . . " <br />Printed / Typed Name I Signature 1 Month Day 1 Year