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DocuSign Envelope ID: 88A54057 -CC31- 4328 - 9012- 2B021842D3E4 <br />EXECUTION OF PROPOSAL <br />PROJECT NAME: <br />HOUSEHOLD HAZARDO€JS WASTE COLLECTIONPROPOSAL REQUEST NO. 236 <br />THIS PAGE MUST BE FULLY EXECUTED AND SIGNED FOR THE PROPOSAL TO BE CONSIDERED. <br />The person executing the proposal, on behalf of the vendor, being first duly sworn, deposes and says that: <br />(1) He is fully informed regarding "the preparation and contents of the attached Proposal and of all <br />pertinent circumstances regarding such Proposal; <br />(2) Neither he, nor any official, agent or employee of the vendor has entered Into any agreement, <br />participated In any collusion, or otherwise taken any action which Is in restraint of free competition in <br />connection with this proposal; and <br />SIGNATURE OF PROPOSAL <br />Clears Harbors Environmental Services .Inc <br />(Print full name of corporation) <br />208 Watlington Industrial Drive, Reidsville, NC 27320 <br />,,? (A�dress - County- State - Zip Code) <br />Attest <br />) David. T. Musselman. <br />By: <br />Pres-ident/Vi f PresfAssist nt Vice President) <br />Printed: Joseph L. McNally, <br />. •.'it <br />i.�`�1ar.ri t�' <br />Title. <br />CORPORATE SEAL: <br />Federal ID. or Social Security Number 04- 269 -8999 <br />f.t; <br />NOTE - AFFIDAVIT MUST BE NOTARIZED <br />Subscribed and sworn to- before me <br />This 9th ay f ,2012. <br />DAVID T. MUSSELMAN <br />W Notary Public <br />COMPA 1VWEALTH OFMASSACHUSHTS <br />My Commission Expires <br />September 18, 2017 <br />Title <br />My Commission Expires <br />Page 17 <br />HHW RFP # 5183 <br />