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HERITAGE ENVIRONMENTAL SERVICES, LLC Heritage use Only
<br /> WASTESTREAM SURVEY FORM
<br /> (877)43$-8778 Quote#: wStk
<br /> t+vwWlr.herita e-enviro.com
<br /> Please review Instructions before completing this form. Business Type- Repeatable: ® Non-Repeatable ❑
<br /> Product
<br /> Code: Price.
<br /> Preferred TSD RoachdaCharlotte NC❑ Coolidge,AZ® Indianapolis,IN❑ Kansas City,Moo Hazardous/s Landfill I] WTI❑
<br /> Location`: Non-ftwrdous Landfill
<br /> Service Albany,NY Blaine.MN East Liverpool,OH❑ Hammond,IN Lemont,IL Lj
<br /> Location': Louisville,KY Signal Hill,CA® St.Louis,Mo Toledo,OH Tulsa,OK
<br /> 1.GENERATOR INFORMATION (Heritage# 64495-6 )" 2.BILLING INFORMATION (Heritage# 125925 )'
<br /> Generator Name TIN, INC(#020-TRACY) Customer Name
<br /> Address 400 WEST VALPICO ROAD-SITE Address
<br /> City,State,Zip TRACY,CA.95376 City, State,Zip
<br /> Tech.Contact Name DAN PEREZ Contact Name
<br /> Phone (209)836.1971 Fax Phone Fax
<br /> 24 Hour Emergenq Number (800)326-1221 E-mail Address
<br /> E-mail Address 3.MANIFEST MAIL ADDRESS(if different from nerator
<br /> US EPA ID Number CAT000610949 Contact Name
<br /> State ID Numbers Company Name
<br /> Status LOG)M SQG El CESQG Address Non-hazardous City,State, Zip
<br /> 4.Generator SIC If 3312,do you perform Coke Oven Byproduct If 28__,2911,3312,or 4953,what Is the Total Annual
<br /> Code 2653 RecoveryOperations?Yes No Benzene AB in M a ram er?
<br /> 5.Common Name WATER BASED INK
<br /> 6.Process Generating Waste FLEXIGRAPHIC&LITHOGRAPHY PRINTING
<br /> 7.DOT Description`(if available)
<br /> NA3082,NQL8CRA H ,N.O.S.,9,PGII1,(INK WATER),ERG#171
<br /> 8. Identify US EPA waste codes PONE
<br /> 9. If D001-D043,are any Underlying Hazardous Constituents(UHCs)present?YesEl Noin NAI]if yes, list in Section 13,
<br /> 10. If F001-F005,or F039,list the F-Usted hazardous constituents in Section 13.
<br /> 11, US EPA Form Code` US EPA Source Code'
<br /> 12. Identify state waste codes 135
<br /> 13.Waste Composition:Using specific chemical names and/or descriptions of waste composition,list all constituents present in the
<br /> wastestreem,and identify those that are underlying hazardous constituents(UHCs),or F001-FO05TO39 hazardous constituents.
<br /> Attach avallable analysis or MSDSs. Total composition must equal or exceed 100%
<br /> Constituents Range Units UHC? F-
<br /> - Listed?
<br /> INK _ —_-- 0-100 % Yes 0 Yes ED
<br /> WATER 0-100 % Yes Yes
<br /> Yes❑ Yes❑
<br /> Yes Yes
<br /> Yes El Yes
<br /> Yes Yes
<br /> Yes❑ Yes
<br /> 14. Color MULTI Appearance Odor
<br /> 15. 15a.Chemical Properties 15b.Physical Pro 3erties at 70°F
<br /> Flash <73 C3 BTUAb <2,000 ® Solid El Free Liquids? Yes Z No
<br /> Point(F°) < 100 ❑ 2,000-6,000 ❑ Liquid ® Will waste dump out of drums? Yes®No❑
<br /> 100-140 ❑ 6,000-10,000 ❑ Sludge ❑ Is the waste pumpable? Yes®No❑
<br /> 141-200 ❑ >10,000 ❑ Semi-solid ❑ Debris?(List type in Section 13) Yes❑No
<br /> >200 ® Powder ❑ Is the waste dusty? Yes❑ No
<br /> Gas ❑
<br /> Boiling < 100 []1 pH 7 %Solids °k Liquids 100
<br /> Point(F°) >100 ® Range Note: *These sections will be completed by Flerita a if left blanc.
<br /> SLMHESWTIWSSF'ORMSEP2008 1 of 2
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