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;lean Earth <br />Page I of <br />Lab Pack Profile — 2111 Century Environmental Services, LLC, Fernley <br />nerator: Vt Cly Am jDiqr~44 6 <br />te: JW. I I / �%24 <br />vvork Order <br />&q�71- <br />Manifest: 0 W 514f3 V-- PAT - <br />Instructions: Fill in the Manifest line number for each line containing lab pack waste. Fill in all applicable <br />waste codes for that line item. Indicate "Y" if the material is subject to 40 CFR 264 Subpart CC <br />requirements (does the waste contain greater than 500ppm volatile organics). <br />Manifest <br />Line # <br />Waste Codes <br />Subject to <br />Subpart CC <br />7i Gt% 7i <br />Z M <br />N <br />Generator Certification <br />I hereby certify, as an authorized representative of the Generator named above, that 2111 Century Environmental <br />Services, LLC has been fully informed of all information known about this waste, including but not limited to, the <br />waste's generation process, composition, and physical characteristics, necessary to identify proper treatment and <br />disposal of waste and this information is true and accurate. In accordance with 40 CFR 264.12(b), 21St Century <br />Environmental Services, LLC has the appropriate permits for, and will accept the waste the generator is shipping as <br />described in this profile. <br />Except as otherwise agreed to in writing between Clean Earth Specialty Waste Solutions (and/or its subsidiaries) and <br />Customer, by signing in the space indicated below, you, on behalf of Customer, acknowledge that you have read and <br />agree to the Standard Terms and Conditions located at <br />www.cleanearthinc.com <br />Generator Name: <br />Generator Signature: <br />