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Common Name(same as Item#5): <br /> 16. Check all that apply. Marking any of these may require additional documentation or follow-up information. <br /> l� 18e. 16b. 16C. <br /> ❑ metalPowder/g_ ❑ Used oil? PCBs? <br /> �k` Palbobmr _ (per 40 CFR 279) Yes E]No® (per 40 CFR 761) Yes El No <br /> Au6oforlit" ❑ Pftolla O .. ❑ <br /> 6"ggiml ❑ Pel ❑ Used oil mixed with If yes,PCB 50 PPM ❑ <br /> t ❑O Radioa02 ❑ hazardous waste? Yes C1 No® concentration? >50 PPM ❑ <br /> Sanitary <br /> ❑ .,.,,. ❑ <br /> corripmaw C" 13 sensim 11gi I _4 13rxiousiy�_ Total Halogens <1000 PPM El Greater than 50 Yes❑ No❑ <br /> Imo,,,_ ❑ rM l ❑ (TX)concentration? > 1000 PPM❑ PPM source? <br /> lt�iade ❑ <br /> 0 Temperature 16d. <br /> Insecticide ❑ Control Reaulred ❑ <br /> Lab Pack [3 <br /> . �� Does this material require any specie!handling? Yes[INo <br /> Medicail . ^@ ❑ <br /> w ❑ Ifs,a Iain: <br /> 1�• 1 Bf. <br /> Volatile Organic Compound>500 PPM? Yes❑No® Do any exclusionslexemptions apply? Yes❑No <br /> Subject to Subpart CC? If yes,note the exclusion/exemptlon: <br /> (per 40 CFR 265.1080-1091) Yes❑ No <br /> 16g. 16h. Additional Comments: <br /> Generated from electro atl ? Yes❑ No <br /> 17. Transporter.Heritage Transport ®Other ❑(Complete below) 18.Packaging: Size: 19.Volume: <br /> Transporter Name Bulk Liquid <br /> Address Bulk Solid ❑ <br /> City,State,Zip Cu Yd Bag/Box ❑ !Year <br /> Contact/Phone Cylinder ❑ <br /> Drum ® /Shipment <br /> US EPA ID No. Tote(Metal) ❑ <br /> Tote(poly) <br /> 20. Check or List Attachments: Lab Data in MSDS Cinder Form LJ Packi List Other list <br /> j El <br /> 21. CERTIFICATION Sign and date the cert cation. <br /> I hereby certify that I am an authorized agent of the generator,and warrant on behalf of the generator,that all information submitted <br /> herein and attached documentation contains true,accurate and complete descriptions of this material. Any sample submitted for <br /> analysis is representative of the material being offered for approval. All relevant information regarding known or suspected hazards in <br /> the possession of the generator has been disclosed. I will notify Heritage Environmental Services,LLC or Heritage-WTI,Inc.of any <br /> changes in generator status,any information on this form,or any information on the attachments. This certification and signature <br /> apply orm,to all attachme t pecked in section 20,and W land disposal�Dj <br /> riction n tification (LDR)generated from this <br /> information. 5 vSignature Printed Name Compan <br /> 22. COMPLETE THIS SECTION FOR NON-HAZARDOUS MATERIAL BEING MANAGED TO A NONHAZARDOUS PROCESS <br /> EXAMPLE: SUBTITLE D LANDFILL or MASS-BURN <br /> 22a.floes this waste exhibit the chemical characterfzadw of an oxidizer? Yes rJ No ❑ <br /> .22b.Is figs waste a listed 22c.This waste is not characteristically hazardous for DOC/-DO43 based on attached lab <br /> waste?(U,P,K,or F codes) Yes❑ No Q 1 data mark LD, attached MSDS mark MSDS),or 1 enerator know ied mark GK). <br /> 10001(Ipnitabi►tty) ITCLP VOLATILES I TCLP SEMI-VOLATILES D038 Pyridine <br /> 17002(Comosiviry) 13018 Benzene —_ __ 13023 o Cresol D041 2,4.5-TAchlorophwa <br /> 13003 2!g4 D019 Carbon Tetrachloride _ 0024 m•Cresol13042 2 4,8-Te thloro herror <br /> TCLP METALS D021 Chlorobenzene D025 p-Cresol FiER81CtCE$S P1E:S710DES <br /> D004 Arsenic D022 Chloroform 0026 Cresol D012 Endrin <br /> D005 Barium 0026 1,2-01chloroethane D0271,4-Dichlorobenzene 0013 Lindane <br /> D006 Cadm(um D029 1.1-DoNomethylene 0030 2,4.01nlirotoluene D014 kiethorritor <br /> 0007 Chromium 0035 Me"Ethyl Ketone D032 Hexachlorobenzene D015 Toxaphene <br /> D008 Lead _ D039 Tetrachloroethylene D033HexacNorobutadiene D016 2.4-13 <br /> D009 Mercury D040 Trichloroethylene D034 Hexaachloroethane D017 2,45-TP(SiNex) <br /> D010 Selenium D043 Vinyl Chloride 13036 Nilrabenzerae IX?20 CNordane <br /> 13011 WarD037 Pentachloro henol 0031 Heptachlor <br /> SLMHESWTIWSSFORMSEP2008 2 of 2 <br />