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Waste J;MsystemsrM WCD No. SS 44001 BROWNING-FERRIS INDUSTRIES C4 40 I 110572- BFI 103SZBFI WASTE CODE WASTE EVALUATION REQUEST-' BFI to complete this area. BFI Initiator Disposal Method Requested O� orkmg Face ❑Other ❑ it� Cover W Location �. Company Number Date Disposal Site Requested Telephone Number( ) Company Number A P.O.Number Action Requested: ❑ RCI -24 Hour Response Analyses Requested: ❑ TCLP f❑;RCI ,❑ Oil Sheen �+#cs ,: ❑ RCI, TCLP- 5 Day Response ❑TPH ❑ BTEX ❑ PCBs 'Other" ?fix . ri7i? ❑Other Analyses To Follow: ❑TCLP ;:❑.Other. "�r H WASTE CHARACTERIZATION DATA A � ;�},, UST Contaminated Soils " ' ' '' ''" "''' e�kTisi•i,: IMPORTANT:THIS FORM IS TO BE COMPLETED BY A REPRESENTATIVE OF THE PARTY RESPONSIBLE FOR THE STORAGE TANK OR BY A REPRESENTATIVE OF THE PARTY TO BE INVOICED FOR DISPOSAL, IF DIFFERENT. PLEASE READ THE INSTRUCTIONS BEFORE COMPLETING THIS FORM. SINCE THIS FORM NAS BEEN ASSIGNED A UNIQUE WCD NUMBER, IT IS TO BE USED ONLY ONE TIME. INSTRUCTIONS: This form is to be used only to describe contaminated soils that are not designated as hazardous waste by the USEPA offered to BFI for disposal resulting from the removal of underground storage tanks(UST)once containing gasoline,diesel fuel, heating oil or vehicle drain oil from non-industrialized areas sµch as service stations, automobile dealerships, residences and transport terminals.This form is not intended to be utilized to describe storage tanks and associated piping. If the waste is not described in Section 2a, then the BFI Special Waste Characterization Data(WCD)form must be used to identify the waste.This form must be typewritten or legibly printed in ink, and signed. Do not alter the content of this form. 1. GENERATOR INFORMATION a) Generator's Name: e)Customer's Name: fie"/ .4 749A) b) Generating Fa ilityAddress: �� 6 7 Customer's Address: 7 C��?r City: t C `r S ate:.(A Zip: _ City: � n � State: /ZipVgC c) Compare Representative: _ g)Telephone No.( 2a93 Z - 9 /O Title- any: After Hours No.( ) d) Emergenc ontact: 020 — Z - F 73 Emergency No.( ) Title 2.GENERAL WASTE STREAM INFORMATION * � a;• v +- �,. I� .,� a) Description of The Waste: 1) ❑ Soil contaminated with leaded gasoline 4) ❑ Soil contaminated with heating oil 2) ❑ Soil contaminated with unleaded gasoline 5) ❑ Soil contaminated with vehicle drain oil 3)IBGSoil contaminated with diesel fuel 7. /� b) 'Type of facility generating the waste soil: c) Anticipated Volume: �n O ❑Tons J�;Cubic Y rds ❑Other d) Is this a "Hazardous Waste" as defined by State or local Regulations? ❑ Yes (� No If yes,enter the Waste Identification Number, if one has been assigned: e) Is this a "Special Waste", an "Industrial Process Waste", or a "Pollution Control Waste" as defined by State or local Regulations? ❑Yes t9 No If yes,enter the Waste Identification Number, if one has been assigned:: f) Is this waste subject to the UST corrective action regulations under 40 CFR 280?N Yes ❑ No. g) Recommended personal protective equipment and special handling procedures: �tiOhC� h) Has a representative sample of the contaminated soil been provided to BFI for testing and evaluation? ❑ Yes �(No. If yes,complete the Representative Sample Certificate below.