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..ach results and chain of custody dots for all analyses performed on the subject waste within the previous 12 months. <br />Vi. Random Sampling <br />Twin performs random sampling and analysis for hazardous waste characteristics and constituents of wastes <br />provisionally accepted at the site. If your waste is selected for random sampling, a sample will be collected at the <br />time of receipt of the waste. If the results of random sampling and analysis indicate that the waste was <br />hazardous, the Generator shall pay for said analysis, and be financially and legally responsible for retrieval, <br />transport, and disposal of the-hazardous waste at no cost to Twin. 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 fort?expenses ?related to transportation, storage and handling of the non-conforming waste. <br />Name: E Yra„!ritC4 f how dk3 <br />(Print or type) (Signature) <br />Title: &c_Q to O.&I <br />VIII. Waste Acceptance <br />Date: 3/( :?;/o P <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. Waste 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 />Signature of Authorized Twin Representative <br />www.twinenviro.com <br />Date: