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-01:07:00 p.m, 09-29-2011 4/4 <br /> � w REPUBLIC <br /> SERVICESs INC. <br /> NON—HAZARDOUS WASTE MANIFEST <br /> GENERATOR INFORMATION CUSTOMER/BILLING INFORMATION <br /> ACTON MICKELSON <br /> Generator Name: GEORGIA PACIFIC CORP. Billing Name: ENVIRONMENTAL INC. <br /> Address 133 PEAC14TREE ST.NE Address 1107 INVESTMENT BLVD#290 <br /> city; ATLANTA County, City: EL DORADO HILLS County: <br /> state GA Zip; 30303 Slate: CA - zip: 95762 <br /> Site Lneation(Ifdltrerent): 75 W.VALPICO ROAD TRACY <br /> Repuhllcsomees Description of Waste Volume/Weight Expiration Container Type <br /> A roval# Date <br /> 38501115486 CONTAMINTED SOIL-ADC 60/CY 3/31/2012 <br /> ' *Attach Additional Sheet if necessary <br /> I hereby cortify that the above described materials are nonhazardous wastes as defined by 40 CFR 261 or any applicable state law. <br /> Further,that the above named materials are properly classified,described,packaged,marked and labeled,and are in proper <br /> �� <br /> p ditionfortmnsportntlonaccordingto c applicable regulations of the Department of Transportation. <br /> �v n G �c <br /> "Jake. 73 <br /> Generator/AuthorizedAeeutNamc Siennture Date Shinned <br /> '611V-41"— �/l3 °! ` TRANSPORTER INFORMATION <br /> Transporter Name: DOW <br /> Transporter Address: 5/�rj Et?�ya//J(? �`��✓f !/? Truck Number; 2-Z <br /> Phone Number: �"d,--?�1 6 <br /> I certify no hazardous waste or other regulated substance was knowingly introduced to the waste while in my custody. The waste <br /> transported in this <br /> vehicle is the waste identified above,to the best of my knowledge <br /> i <br /> Meme of Authorized Agent f Signature<z/� Date Delivered <br /> DISPOSAL SITE INFORMATION <br /> SiteNnme, — VASgqJWAR LANDFILL Phone No. 9254470491 <br /> Site 4-21yral Igo Mr'(1 4001 VASCO ROAD LIVERMORE,CA <br /> Lru <br /> I her y acknowledge receipt of-the above desra ad materials. <br /> OCT 2 4 2011 <br /> Dillard I C._l '' /o-/ -'// <br /> ' Name rintorTypeplyronr CAS t Signature Date Received <br /> f <br />