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Oct 26 01 04: 57p Gu, n Birdsong 209-234-2411 p• 4 <br /> wjuu;::005 <br /> l� <br /> GENERATOR WASTE PROFILE SHEET <br /> �- Waste Pro le 4 <br /> Requested Disposal FaWity. <br /> an AMcd Wasrr Company <br /> I. GENERATOR INFORMATION Date; /6— (a — O/ <br /> Generator Name; p i Co <br /> Generator Site Address: 3 S C M ,e/ otA/ <br /> City' +JG K fO A" County: �"' State: C.q Ztp: y 5 �,/ <br /> Generator State ID No: SIC Code No: <br /> Generator Mailing Address(if different): C P A./f r^1�-e Or <br /> City: q A Ing A I County: I Sate: a zip: <br /> Generator Contact Name: <br /> Phene Number. C1 a, _ a I q - Fr I Fax Number: <br /> II. TRANSPORTER INFORMATION <br /> r <br /> msporttt Name; N /dnsporter Address; �� I l fG C: p -V*' 8 <br /> Y .i+e.. Crnunry: BL e..�o State: Zi : L• <br /> Transporter Contact Name; G� A.1 e A,4/`A e 5 <br /> ` d <br /> Phone Number: /6_31 , o'8 Fax Number. f ' S'1 -/57 state Transportation 0: 0193,3 6 q <br /> III. WASTE STREAM INFORMATION <br /> Name of Waste: -6 <br /> Pracus Generating Wasle: K PVtsVa L ♦rl. Qct r•rl <br /> Type of waste: UUSTRIAL PROCESS WASTE) or POLLUTION CONTROL WASTE <br /> Physical State: SEMI-SOLID POWDER LIQUID OTHER: <br /> Method of Shiprumc UL DRUM BAGGED OTHER IEXPLAIN: <br /> Estimated Annual Volume: CUBIC YARDS: O TONS: 2w OTHER: <br /> Frequency: ONE TIME ONLY DAILY WEEKLY MONTHLY OTHER I EXPLAIN: <br /> SPECIAL HANDLING INSTRUCTIONS: Now L <br /> IV. REPRESENTATIVE SAMPLE CERTIFICATION 0/UG p — y <br /> Is the n:presemative sample collected to prepare this profile and laboratory analysis.collected in accordance <br /> with U.S.BPA 4 40 CER 261.20(c)guidelines or equivalent rules? YES or NO <br /> Sample Date. Circle one: COMPOSITESAMPLE GRAB SAMPLE <br /> Sampler's Employer: <br /> L Sampler's Name(printed):) Signature: <br />