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x <br /> 11VSTRUMONS + — <br /> Please complete one farm for each type of waste stream. Do not mix waste either in the field or during shipment to LLe <br /> landfill. ` . <br /> Section A. Name the generator of the waste; usually, the owner of the site or client. r <br /> Section 13: Describe geographical location,of where the waste was rcmovedlexcavated from. Attach a map if necessary. 1 � <br /> Section C: State type of industry and csemicals associated with the Contaminated Soil. <br /> i <br /> Cite the source of the chemical information reported. (For personnel commuair~uion, or report, <br /> include name/title and date). <br /> Sxtion D: List reports that coataia the investigation and chemical characterization of contaminated soil. Attach report <br /> if available.— <br /> Section Z: Check appropriate column for each type of y <br /> If s.i <br /> y ' <br /> anal ses write the number of samples in the'Yes'column. <br /> r� <br /> Section F: Use number of samples and soil volume to estimate represetttative soil volume per sample (e.g., 20 cu <br /> yd/samples) insert`20' i7 the column 'Soil VOi/Sample'. <br /> i <br /> � <br /> Indicate if soil samples were collected in-situ or after stockpiling. ; <br /> Indicate whether'Hat Spots' of the contaminated soils were sampled. <br /> ladicate whether soil samples were composite samples or not. and the number of samples for each <br /> composite(e.g., 4 into l) <br /> Section G: List e:evated conceatntiaas of primary contaminants found in'Hot Spats'. Include priorityorgaaics or metals r� <br /> detected in'root Spot"samples. t <br /> r'l <br /> Avenge conceatratian is the sutistiul avenge of only the samples collected from the waste <br /> i <br /> stream f <br /> that will be received at the landIl. <br /> I <br /> Highest canceatrction is the coocentrat:gin of primary contaminants in "Hot Spot'Samples. <br /> : 1 <br /> 1 Modal concentration is.the most occurring cancen,(tatioR mage detected. <br /> Vol, of waste is an estimated volume of affected soil for the chemieai listed. w. <br /> % vol. of waste is soil volume of affected soil for specific chemicals compared to total. Volume of <br /> r� <br /> affected soil(c.g., 10 cu yd of toluene soil Out of total sail volume of so cu yd caouiniag$TXE is k„5 <br /> L <br /> 20%). <br /> { <br /> _ a� <br /> Section H: �Certifiration. Signature, sea[, date and registration number of Engineer or Geologist is required. <br /> - ?0 102A 09/04/90 <br /> i <br /> � k <br />