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18000222979 01:07:00 p,m, 09-29-2011 414 <br /> w REPUBLIC j <br /> SRRVICHSo INC. <br /> NON-HAZARDOUS WASTE MANIFEST <br /> GENERATOR INFORMATION CUSTOMER/BILLING INFORMATION <br /> ACTON MICKELSON <br /> OoncratorNnmo: GEORGIA PACIFIC CORP. 13111ing Nano: ENVIRONMENTAL INC. <br /> Address 133 PEACliTREE ST.NE Address 1107 INVESTMENT BLVD#290 <br /> City: ATLANTA County: City: ELDORADO HILLS County: _ 0 <br /> state OA zip: 30303 state: CA zip: 95762 <br /> Site Lowden(If difrarent): 75 W.VALPICO ROAD TRACY <br /> Republic Services Expiration <br /> Approval 0 Description of Waste Volume/Weight Date Container Type <br /> 385011154116 CONTAMI ITED SOIL-ADC 60/CY 3/31/2012 <br /> �i <br /> *Attach Additional Sheet If necessary <br /> I hereby cerflj�thetthe above described materials are non-hazardous wastes as defined by 40 CFR 261 or any applioabla state law. <br /> Further,that the above named materials are properly classified described,packaged,marked and labeled,and are in proper <br /> tPndWon for transportation acoordingto applicable.regulations oftheDepartment ofTransportation. <br /> �I0. �acl�i'G ��-�- <br /> u,b e73 X <br /> Generator/AuthorUed Aeout Name §Jynaturc Date Shloned <br /> '01M TRANSPORTER INFORMATION <br /> Transporter Name: AlIt 6 A/ U r/i„ ry e ,,,r DOTrF '—/��lic 0u 04 f : 't <br /> .. <br /> Transporter Addrass: �.t.af .� (irrtlt T` Truck Number: I e7 <br /> � l,.f�e7" c'. // Phone Number: ,5-1 ),_(el I <br /> I certify no hazardous waste or other regulated substance was knowingly introduced to the Waste whiia in my custody. The waste <br /> transported'In this vehicle is the waste Identified above,to the best of my knowledge. <br /> Name of Authorized Agent Signature Date Delivered <br /> DISPOSAL SITE INFORMATION <br /> Site Nomei VASCO ROAD LANDFILL Phone No. 925 447 0491 <br /> Site Address;, 4001 VASCO ROAD LIVERMORE CA <br /> I hereby acknowledge receipt of the above described materials, <br /> Name(Print or Type) Sifnaturc DateReoeived <br />