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02-25-'15 15:14 FROM- CoI*nvi ronmenta I djzi� v iDT-440 P0002/0002 F-919 <br /> clu�b ;a VelfO.f IISC® APR 0S 2015 <br /> r internal Use only <br /> / ENVIRONMENTA JobNumberl <br /> WASTE PRODUCT QUESTIONNAIRE <br /> 1.GCNPRALTNFOPMATION FAX (562)495-2101 96571 <br /> Generator NnmePacific Southwest lrrtgation 1BillingNams, COLESENVIRONMENTAL <br /> Address_37$ Z S 4I@ck Tone Road _ Address PO BOX 10764 <br /> City,Stxte,Zip �q�(p C 95 City,Stare,Zip B33 �ELD, CALIF 93389 <br /> Contact Colin-Kel)v 1 eorge owrv) Conran MARY MILLER <br /> Phan' -8 0 rax 209/578-0142 -- — <br /> EPA Number CAL000358877 Phone 681!322-8258 pox 661/322-8883 <br /> II.WASTE PRODUCT DESCRIPTION&CHARACTERISTICS <br /> A.Waste Product common Name AdheS(ye(Weldon-On Products) <br /> 1.Proteus Generating Waste Site Cleanup-Daily Operations <br /> B.Hazardous Properties: ' <br /> 1-U.S.EPAHezardous Wasta? ®Yes []No 2- State Code(s): 331 _ <br /> EPA Code(s): D001 <br /> o.Is Waste Product: OShock Sensitive 13 Reactive ❑rtadloacrive ❑Pyrophorle ❑Etiological Q✓ Nona <br /> C-physical Properties at 70'F: <br /> 1.Physical State: 2.Layers 8.Flesh Point(Closed Cup Only): 4.Viscosity similar to: <br /> ❑Solid t]Sludge ❑Multilayared [I<70'F 11140-200°F ❑Water <br /> ID Liquid []Empty Container p SI-Layored ❑70.100'F []No Flash ❑Motor Oil <br /> ❑Aerosol 0Homogenous E(10i-1390F El Exact ❑Honey <br /> Any free liquids at 70'F 0 Other <br /> ❑Yes U No <br /> D. d.Density 2.%Solids a.Odor 4.Ph, <br /> Liquid IZLIbstgallon 0 By Weight ❑None 13<2 139.1-12.5 <br /> Solid ❑_•_ lbstoublc it. El BY Volume []Strong 02-5 ❑ 12.6 <br /> Any debris in waste: Total ❑Mild E3 5.1-9 ❑Exact <br /> U Yes V No Describe: <br /> Explain <br /> Mal NONE NONE <br /> E. Chemical Composition(Account for 100%of total): Ringo Total(PPM) Pesticides,Herbicides:PPM <br /> Adhesive 100 — 100 -,6 _gp Toxloily(mgli) Endlln. . - . . _ <br /> Arsenic(As) Undane. . . . . <br /> MSDS SHEETS ATTACHEg - _% Sarlum(Be) Methoxychlor <br /> 55 cadmium(Cd) Toxaphene <br /> —_. !^ Chromium(Cr) 2,4-D <br /> Cappor(Cu)_------_ 2,4,5•71` <br /> Lead(Pb) Other <br /> — <br /> % Mercury(Hg) <br /> % Nickel(NI) Reaclives&Other <br /> u — Selenium(Be) Wastes(PPM): <br /> v< <br /> — ./y Silver(Ag) — Cyanides—Dioxin <br /> -- % Zinc(2n) Sullldes___PCBs <br /> F Shipping and Handling)nronnallon: I HOC_Phenols <br /> 1.D.01 hazardous Material?,®•Yes•t_,,,two <br /> ..2.Proper D.O.T.Shipping Name: UN 1133, Waste Adhesives, [containing a flammable licluid], <br /> S.D.O.T.Hazard Class: 3, 4.D.O.T.ID Number.UN1133 —PG. PGI( _ <br /> 5.Method of Shipment:___ Drum and?or_--_Bulk____Other 6.b.O.T.Shipping Container, 55-ul drUms (GI&Qt cont) i <br /> 7.Projected Volume: Tbns Gallons Cubic Yards Other 8.R0 Amount__ <br /> Per_1 to 4 One Time Week Month -____-_Quarter x Yesr <br /> Comments: <br /> j GENERATOR CERTIFICATION STATEMENT <br /> '`_.,• I hereby certify that as an authorized representative of the generator named above,all information submitted in this and all attached documents <br /> is true and/aocurals-Analysts of the waste was conducted in accordance with the approved rest methods In 40 CFR 261 on a ropresentativo aamplo <br /> defined In 40 CFR 261.20,To the best of my knowledge,all[mown (40 CFR 261)and suspected hazardous components have been Included in <br /> this duan' l� • e - Aply with all current regulations. <br /> Signature — n / L <br /> 19115 <br /> FORM <br /> FORM 402(Roy.03110)— <br />