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' r <br /> GENERATOR WASTE PROFILE SHEET Page 1 of 2 <br /> ALLIED WASTE <br /> Waste Profile# <br /> Requested Disposal Facility: Forward Landfill <br /> an Allied Waste Company AWi Sales Rep: <br /> I. Generator Information Date: 2-15-05 <br /> Generator Name: Ernest J Pomba JR <br /> Generator Site Address: 24100 Lammers Road <br /> City: Tracy County: San Joaquin State: ca Zip: 95376 <br /> ' State IDIReg No: State ApprovalNllaste Code: (if applicable) SIC Code: <br /> Generator Mailing Address (if different): 1755 1I'h Street <br /> City: Tracy I County: San Joaquin State: CA Zip: 95376 <br /> Generator Contact Name: Michael J. Kloberdanz <br /> Phone Number: 209-577-8186 Fax Number: 209-577-$158 <br /> ' Ila. Transporter Information <br /> Transporter Name: Land Tech Contact Name: Richard Hamilton <br /> ' Transporter Address: P.O. Box 4500 <br /> City: Modesto County: San Joaquin State: CA Zip: 95352 <br /> Phone Number: 209-574-1230 Fax Number: 209-574-1229 State Transportation Number: 208548 <br /> Ilh. Billing Information <br /> Bill To: M.J. Kloberdanz &Associates Contact Name: Michael J. Kloberdanz <br /> Billing Address: P.O. Box 5769$1 <br /> City: Modesto State: CA Zip: 95357 Phone Number. 209-577-8186 <br /> III. Waste Stream Information <br /> Name of Waste: Petroleum contaminated Soils <br /> Process Generating Waste: Excavation from leaking underground fuel tank <br /> Type of Waste ❑ INDUSTRIAL PROCESS WASTE or ® POLLUTION CONTROL WASTE <br /> Physical State: ® SOLID ❑ SEMI-SOLID ❑ POWDER ❑ LIQUID ❑ OTHER: <br /> ' Method of Shipment: ® BULK ❑ DRUM ❑ BAGGED ❑ OTHER: <br /> Estimated Annual Volume: ❑ CUBIC YARDS: ® TONS: 1950 ❑ GALLONS ❑ OTHER: <br /> Frequency: ® ONE TIME ❑ DAILY ❑ WEEKLY ❑ MONTHLY ❑ OTHER: <br /> Special Handling Instructions: <br /> IV. Representative Sample Certification ❑ NO SAMPLE TAKEN <br /> ' Is the representative sample collected to prepare this profile and laboratory <br /> analysis, collected in accordance with U.S. EPA 40 CFR 261.20(c)guidelines or-- ® YES or❑ NO <br /> equivalent rules? <br /> Sample Date: 02/08/05 Type of Sample: ❑ COMPOSITE SAMPLE ® GRAB SAMPLE <br /> ' Laboratory: GeoAnalytical Laboratories, Inc. Sample ID Numbers: R039-04 (PQ-1, 2, 3, &4) <br /> Sampler's Employer: M.J. Kloberdanz& Associates <br /> ' Sampler's Name (printed): Michael J. Kloberdanz Signature, <br /> ' REV 1 ©Allied Waste,February 2001 <br />