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D. AUTHORIZED SIGNATORY: Pg.2 <br /> I hereby attest under penalty of perjury that: <br /> • I am the Generator (or authorized by the Generator identified herein to provide the information submitted in this form and any <br /> attached documents and to enter into this Agreement on the Generator's behalf). <br /> 0 I completely investigated all matters relevant to completion of this form and based on this investigation attest that no hazardous <br /> waste codes are associated with this media. <br /> • If laboratory analysis was used to evaluate this media, the analysis was performed on a representative sample of the media in <br /> accordance with 6CCR 1007-3 Section 261.20(c). <br /> • All applicable information concerning the media has been provided in this and the attached documents. Such information is <br /> complete and accurate and all known or suspected hazardous constituents/characteristics or safety hazards associated with the <br /> media have been disclosed herein. <br /> • I understand that the media may be subject to random sampling and analyses, and conditions that any media non-conforming will <br /> be rejected and/or returned to the Generator. Generator is liable for expenses related to transportation, storage, handling, and <br /> disposal of any returned non-conforming media. <br /> Signature: Print: <br /> Title: Date: <br /> Company: <br />