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-,SID W <br /> REPUBLIC ��ps <br /> SERVICES <br /> THIRD PARTY SIGNATURE AUTHORIZATION <br /> for Special Waste Disposal CIV <br /> Date: I-)-- I �— APR 08 2015 <br /> This Authorization is only valid for 3 years ENVIRONMENTAL <br /> the above date. <br /> HEAITN nFoaoTeeeniT <br /> To Whom It May Concern: <br /> Please be advised that the following company/individual has been appointed to work as our <br /> agent for purposes of managing waste materials that we may generate. <br /> Name of Authorized Agent Title ��I��r� tM �( �yr � <br /> Alun�y�T <br /> Name of Company Telephone Number <br /> GwPSeLf/L�w.y 6�c � ��� s4�-07C <br /> �• The above broker/individual is authorized to act as our authorized agent for the following <br /> purposes: <br /> Complete and sign Special Waste Profile. <br /> Complete and sign Special Waste Profile-Recertification. <br /> Authorize amendments to Special Waste Profile. <br /> ❑ Sign contracts to dispose and/or transport material. <br /> RSign certifications necessary to comply with landfill requirements. <br /> Sign manifests to initiate shipment to disposal facilities. <br /> Our authorized agent will notify us prior to any action stated above, and will provide us with <br /> copies of any documents bearing our name. <br /> Name of Company Mailin Address <br /> &' c c, GQ <br /> Generator Contact(Print Name) Title <br /> w R, u Jae r <br /> Signature Telephon Number <br /> /9y7 <br /> April 2013 <br />