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WWRA. WASTE MANAONMENT EZ Profile TM4/ Requested Facility: Kettleman Hills (Hazardous Waste Facility) ❑ Unsure Profile Number: CA611676 ❑ Multiple Generator Locations (Attach Locations) ❑ Request Certificate of Disposal ❑ Renewal? Original Profile Number: A. GENERATOR INFORMATION (MATERIAL ORIGIN) 1. Generator Name: 7 -Eleven, Inc. 2. Site Address: 1399 N. Main Street (City, State, ZIP) Manteca CA 95336 3. County: San Joaquin 4. Contact Name: Larry Moothart 5. Email: Lar Belshire.com 6. Phone: (949) 460-5200 7. Fax: (949) 460-5210 8. Generator EPA ID: CAD981465438 ❑ N/A 9. State ID: ld N/A C. MATERIAL INFORMATION 1. Common Name: Non RCRA Hazardous Waste, Solid Describe Process Generating Material: ❑ See Attached UST -Gasoline Piping Removal. The UST components contained unleaded gasoline. Product has been thoroughly rinsed and contains no remnants of gasoline. 2. Material Composition and Contaminants: ❑ See Attached 1. Pol yethyl ene Flex Pipe 40-60% 2. Dispenser Sumps 20-30% 3. Sump Collars 20-30% 4. Total comp. must be equal to or greater than 100% >_ 100% 3. State Waste Codes: 352 4. Color: Varies 5. Physical State at 70°F: fits Solid 6. Free Liquid Range Percentage: _ ❑ Liquid ❑ Other: to 7, pH: to 8. Strong Odor: ❑ Yes 68 No Describe: - 9. Flash Point: ❑ <1407 ❑ 140* -199°F ❑ N/A m N/A A N/A ❑ 2-200° fid N/A E. ANALYTICAL AND OTHER REPRESENTATIVE INFORMATION 1. Analytical attached ❑ Yes Please identify applicable samples and/or lab reports: 2. Other information attached (such as MSDS)? ❑ Yes B. BILLING INFORMATION ❑ SAME AS GENERATOR 1. Billing Name: Belshire Environmental Services, Inc. 2. Billing Address:25971 Towne Centre Drive (City, State, ZIP) Foothill Ranch CA 92610 3. Contact Name:Keith Jenson 4. Email: Keith.JensonggDBelshire.com 5. Phone: (949) 460-5200 6. Fax: (949) 460-5210 7. WM Hauled? ❑ Yes 6d No 8. P.O. Number:275705 9. Payment Method: 6d Credit Account ❑ Cash ❑ Credit Card D. REGULATORY INFORMATION 1. EPA Hazardous Waste? ❑ Yes* fd No Code: 2. State Hazardous Waste? 2 Yes ❑ No Code: 181 3. Is this material non -hazardous due to Treatment, ❑ Yes* Id No Delisting, or an Exclusion? 4. Contains Underlying Hazardous Constituents? ❑ Yes* ® No 5. From an industry regulated under Benzene NESHAP? ❑ Yes* 0 No 6. Facility remediation subject to 40 CFR 63 GGGGG? ❑ Yes* Gd No 7. CERCLA or State -mandated clean-up? ❑ Yes* 6d No 8. NRC or State -regulated radioactive or NORM waste? ❑ Yes* 0 No *If Yes, see Addendum (page 2) for additional questions and space. 9. Contains PCBs? 4 If Yes, answer a, b and c. ❑ Yes 64 No a. Regulated by 40 CFR 761? ❑ Yes ❑ No b. Remediation under 40 CFR 761.61 (a)? ❑ Yes ❑ No c. Were PCB imported into the US? ❑ Yes ❑ No 10. Regulated and/or Untreated ❑ Yes 64 No Medical/ Infectious Waste? 11. Contains Asbestos? ❑ Yes fits No -) If Yes: ❑ Non -Friable ❑ Non -Friable - Regulated ❑ Friable F. SHIPPING AND DOT INFORMATION 1. fid One -Time Event ❑ Repeat Event/Ongoing Business 2. Estimated Quantity/Unit of Measure: 20 66 Tons ❑ Yards ❑ Drums ❑ Gallons ❑ Other: 3. Container Type and Size: 20 cu yd. roll off bin 4. USDOT Proper Shipping Name: Non RCRA Hazardous Waste, Solid LEE, It W G. GENERATOR CERTIFICATION (PLEASE READ AND CERTIFY BY SIGNATURE) By signing this EZ Profile'"' form, I hereby certify that all information submitted in this and all attached documents contain true and accurate descrip)1 ra'Cof ti�abil5and that all relevant information necessary for proper material characterization and to identify known and suspected hazards has been provided. Any analytics data attached was derived from a sample that is representative as defined in 40 CFR 261 - Appendix 1 or by using an equivalent method. All changes occurring in the character of the material (i.e., changes in the process or new analytical) will be identified by the Generator and be disclosed to Waste Management prior to providing the material to Waste nManag Q AL HEALTH If I am an agent signing on behalf of the Generator, I have confirmed with the Certificatit�j�l�Ar>ttltfb` Generator that information contained in this Profile is accurate and complete. DEPARTM Name (Print): Larry Moothart Date: 12/06/2016 Title: Manager Company: Belshire Environmental Services, Inc. Revised June 30, 2015 THINK GREEN® QUESTIONS? CALL 800 963 4776 FOR ASSISTANCE 02015 Waste Management