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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-22-182 <br />Waste Tracking (Manifest) Number <br />400-13-32626 -sit 03q <br />Customer Billing Name and Mailing <br />ANCON <br />570 Business Park Drive, Suite 110, Lincoln, CA 95648 <br />Customer Billing Phone: (916) 917-6328 <br />Generator's Site Address <br />Diaz Transport: HVVY 120 and Yosemite <br />Lathrop, CA 95330 <br />Generator's Phone: (831) 320-0051 <br />Avenue <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 />1 Non-Hazardous Soil 1 CM 20 Y ADC <br />2 <br />3 <br />4 <br />Special Handling instructions and Additional information <br />Wear appropriate PPE when handling. Job #400-13-32626 <br />24 Hour Emergency Response <br />800-556-9090 <br />Phone <br />glill * F ti ft)i-7 <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 to the <br />by 40 CFR 261 or any applicable <br />applicable regulations of <br />state law. Further, that <br />the Department of Transportation. <br />the above named <br />Generator's Offeror's Printed / Typed Name <br />Roger Chesshire on behalf of Diaz Transport <br />Signature <br />Roger Ch essh i rec'91"97°,,,,7,t9:',40Ithp <br />Month <br />March <br />Day <br />g <br />Year <br />2022 <br />TRANSPORTER SECTION <br />Transporter's Acknowledgement of Receipt of Materials r, r Signature <br />24.1.-e <br />) (— Month <br />"Y <br />Year Transporter 1 Printed /(Typed N <br />„4------- / 0 <br />Transporter 2 Printed / Typed Name Signature <br />% <br />._ <br />try t i re <br />Month Day Year <br />DESIGNATED FACILITY SECTION <br />Discrepancy <br />Discrepancy indication Space D Quantity CI Type <br />MAP <br />du . .. In ei n 4112j U Partial Rejection 0 Full Rejection <br />2/ <br />Alternate Facility (or Generator) 14 <br />- <br />N Facility's Phone: C/ tOSh <br />US EPA ID Number <br />Signature of Alternate Facility (or Generator) Month Day Year <br />Designated Facility Owner or Operator. Certification of Receipt of materials covered by the manifest except as noted in Discrepancy section <br />Printed / Typed Name Signature 1 Month Day I Year