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.GV/ 1V/ 161/V1 I'"- <br /> GENERATOR WASTE PROFILE SHEET <br /> Waste Profile# <br /> Requested Disposal Facility <br /> an AUIed Waste Company <br /> I. GENERATOR INFORMATION ,[ Date: G-/,Z-o <br /> Generator Nance �i�/r r, /dna �'` eof <br /> Generator Site Address6' Xz dei' <br /> City .�if&,M::!! County <mh State r✓ Zip- qS.2 a 7 <br /> Generator State M No Go4IJ q8'I!{X 84 ys' SIC Code No <br /> Generator Mailing Address(if different) Amo I.?GX / 6k <br /> State- C <br /> City c �A4me 76s I County, _5 lodyr,��o <br /> Generator Contact Name- X'Ay MaAMcc. /I" <br /> Phone Number: �9/6� Numbet: �q/6 978 <br /> IY. TRANSPORTER INFORMCATION <br /> Transporter Name` mod lP SG Mf -0.4e <br /> Transporter Address X8 96 47t,006, 6t ec/ 01 <br /> county. Io�ao.o Stata• 019 zip 9 1 <br /> Transporter Contact Name m4}k /�I7anI <br /> Phone Number C9�6�3�/~ S 7 3 Fax Number: X9/6 �8t' ~!s State Transportation#• T <br /> III. WASTE STREAM INFORMATION <br /> Name of waste p I#, G. %�r e�•i'�� cu el cr�i�e • ll <br /> Process Generating Waste, Od-r ® tom" '0 • <br /> Ito <br /> of waste 1NDUSTRIAf.pRocESS WASTE or POLLUTYON CONTROL WASTE <br /> 2 <br /> Ph steal State SOLID SPMI-SOLID POWDER LI UID OTHER: <br /> Method of Sh, meat• BULK DRUM BAGGED OTHER SIN <br /> OTHER <br /> Estated Annual volume CUBIC YARDS <br /> ut, <br /> Prequcnc ONir TIME ONL DAJLY WEEKLY MONTHLY OTS/EXPLAIN <br /> SPECIAL HANDLING INSTRUCTIONS ��e <br /> IY. REPRESENTATj O SAMPLE CERTMCATION <br /> Is the repr+esentabve sample collected to prepare this profile and laboratory analysis,ooilected in accordance Or NO <br /> wlth U.S EPA§40 CFR 2,6120(0)guidelines or equivalent rules? <br /> �1el Circle owCOMPOSITESAMP GRAB SAMPLL <br /> Sample DateD/ <br /> Sampler's Employer C�/� �" //�+ ec►f <br /> Sampler's Name(printed) G L �an GefJC' Signature` <br />