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to 01101JUI1, al lu ulsNuaai vi rnt3 nazaruous waste at no cost to I win. By execution of this document, the Generator <br />agrees to indemnify Twin from, and agrees to defend Twin against, all liabilities associated with the handling of <br />Generator's hazardous waste. In addition the Generator shall be responsible for all cleanup costs associated with <br />contamination of any Twin facility as a result of delivery of hazardous waste to the facility. <br />VII. Certification <br />I hereby certify that I am the Generator, or I am authorized by the Generator to provide the information submitted <br />in this form including any attached documents and to enter Into this Agreement on the Generator's behalf. I have <br />made a complete and thorough investigation of all matters relevant to completion of this form. This investigation <br />included laboratory analysis, where applicable, performed in accordance with 6CCR 1007-3 Section 261.20(c) on <br />a representative sample of the waste. All required information concerning the waste, Including the results of all <br />laboratory analyses has been provided in this form and the attached documents. I further hereby certify that such <br />information Is complete and accurate and that all known or suspected hazardous constituents/characteristics or <br />safety hazards associated with the waste have been disclosed herein. I understand that the waste may be <br />subject to random sampling and conditions described in Section VI of this form, that any waste that is non- <br />conforming (along with the reagent with which Twin has mixed the waste) will be returned to me, and that Twin will <br />not be responsible for expenses related to transportation, storage and handling of the non-conforming waste. <br />Name: ypo' )1 d rt ?'tfq? 1!S?? -_ ?, all <br />(Print or type) (Signature) <br />Title &e-a I ar]6 <br />Vill. Waste Acceptance <br />Date:_ -Jb240 k <br />The waste, as represented by information contained in this document, is provisionally accepted for <br />disposal at _ Landfill (see Sections VI and VII of this form). <br />Date: <br />Signature of Authorized Twin Representative <br />IX. Writs Rejection <br />The waste, as represented by information contained in this document, is NOT accepted for disposal at <br />the Landfill for the following reasons: <br />Y___ <br />Signature of Authorized Twin Representative Date; <br />www.twinenviro.corn <br />