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1 <br /> 01:07;00 p.m. 09-29-2011 4/4 <br /> 1 C�rib <br /> - REPU BLI <br /> SERVICESs INC.- <br /> NON-HAZARDOUS WASTE MANIFEST <br /> 1 GENERATOR INFORMATION CUSTOMERMILLiNG INFORMATION <br /> ACTON. MICKELSON <br /> 1 OcnerotorName:- GEORGIA PACIFIC CORP. Billing Nome: ENVIRONMENTAL INC. <br /> Address 133 PEA&TREE ST.NE Address 1107 INVESTMENT BLVD#290 <br /> 1 city:_ ATLANTA County: City: EL DORADO HILLS County: <br /> Sato GA zip: 30303 Sate: CA zip: 95762 <br /> 1 Site Location(ifditrerent): 75 W.VALPICO ROAD TRACY <br /> Republic Scrvice_s Expiration <br /> A rovol# Description oCWaste Voiume/Walght Date Container Type <br /> 1 38501115486 CONTAMINTED SOIL-RDC 60/CY 3/3112012 <br /> 1 *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 /> 1 Further,that the above named materials are properly classified,,described,packaged,marked and labeled,and ore in proper <br /> Zee, <br /> nditionfor transportation according to eapplicableregulationsoftheDepaentofTransportation. <br /> rhn <br /> 0V PaCW'C' Z"e--o' / <br /> Generator/AuthorizedAeent Name mature Date Shipped <br /> 1 IA/ <br /> � TRANSPORTER INFORMATION <br /> Transporter Name: -!L1,,4tf_0 171G[EJl_dJ If_)!. DOT# SG�LS <br /> 1 Transporter Address: , =!i� r4441'dG Dl-1'&o Track Number: e!:o <br /> IS <br /> T l,�L ry . �I• ��� Phone Number: <br /> f <br /> 1 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 vehicle is the waste identified above,to the best of my knowledge: <br /> Ile 7 <br /> Name of Authorized Agent / Signatuta Date Delivered <br /> 1 <br /> �� DISPOSAL SITE INFORMATION <br /> U Zf L <br /> Site Name! A COR AD LANDFILL Phone No. 925 447 0491 <br /> 1 SiteA491 4001 VAS CO ROAD LIVERMORE CA, <br /> <ljl pt of <br /> here`b'YY66 I � 4cei t of the above d cribcd materials. <br /> $ �LKtny, 1/7 -- <br /> 1 Yr.Q , Cq " ) �/ <br /> 1 Name(Print or Type) Signature Date Received <br />