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Oct, 06 03 07:44a PA' Environmental (F 7)233-4284 p.4 r Page 3 of 3 IeanHa Profile Number CH 222221 r ENVIRONMENTAL SERVICES. INC. F. REGULATORY STATUS Y N O -1�9- USEPA HAZARDOUS WASTE? (IF Yes List Codes.) CP ❑ DO ANY GENERATOR STATE WASTE CODES APPLY? IF YES, LIST STATE CODES. LIST ANY FEDERAL OR STATE WASTE CODES WHICH MAY VARY FROM SHIPMENTTO SHIPMENT: WILL THE DECISION TO VARY THESE WASTE CODES BE BASED ON ❑ KNOWLEDGE ORO TESTING (check one). v IF KNOWLEDGE, DESCRIBE BASIS OF KNOWLEDGE: ❑ %L IS THIS WASTE PROHIBITED FROM LAND DISPOSAL WITHOUT FURTHER TREATMENT PER 40 CFR PART 268? THIS WASTE IS A: ❑ WASTEWATER NON WASTEWATER PER USEPA DEFINITION IN 40 CFR 268.2. ❑ IF ANY WASTE CODES D001, D002, D003 (OTHER THAN REACTIVE CYANIDE OR REACTIVE SULFIDE), D004 -D011, D012-DO17 NON - WASTEWATERS, OR D018-DO43 APPLY, ARE THERE ANY UNDERLYING HAZARDOUS CONSTITUENTS (UHC'S) PRESENT ABOVE UNIVER- SAL TREATMENT STANDARDS (UTS)? ❑ DOES TREATMENT OF THIS WASTE GENERATE A F006 OR F019 SLUDGE? ❑ IS THIS WASTE SUBJECT TO CATEGORICAL PRETREATMENT DISCHARGE STANDARDS? IFYES, SPECIFY POINT SOURCE CATEGORY LISTED IN 40 CFR PART 401. ❑ IS THIS WASTE REGULATED UNDER THE BENZENE NESHAP RULES? (IS THIS WASTE FROM A CHEMICAL MANUFACTURING, COKE BY- PRODUCT RECOVERY, OR PETROLEUM REFINERY PROCESS?) ❑ DOES THIS WASTE CONTAIN VOC'S IN CONCENTRATIONS Z 500 PPM? �+ ❑ DOES THIS WASTE CONTAIN GREATER THAN 20% OF ORGANIC CONSTITUENTS WITH A VAPOR PRESSURE z .3KPA (.044 psia)? ❑ DOES THIS WASTE CONTAIN AN ORGANIC CONSTITUENT WHICH IN ITS PURE FORM HAS A VAPOR PRESSURE GREATER THAN 77 KPa (11.2psia)? G. D.O.T. INFORMATION: List all s'hippin names that that may be used. Attach additional page if necessary. 1 �+D.O.T.SHIPPING NAME �1 D 1V IC"f ?-A Et AZA"00 S PtSTf: Ps DOT HAZARD CLASS: UN/NA # PACKING GROUP (Circle 1) 1 II III HAZARD ZONE (Circle 1) A B C D .+ WILLTHIS SHIPPING NAME VARY? ❑ Y ❑ N IF YES, WILL ASSIGNMENT OF PROPER SHIPPING NAME BE BASED ON ❑ KNOWLEDGE OR ❑ TESTING? (check ore) IF KNOWLEDGE, DESCRIBE BASIS OF KNOWLEDGE: H. TRANSPORTATION REQUIREMENTS .r ESTIMATED SHIPMENT FREQUENCY: LJ ONE TIME ❑ WEEKLY ❑ SEMI-MONTHLY ❑ MONTHLY ❑ QUARTERLY ❑ OTHER J0 BULK LIQUID GALLONS/SHIPMENT: L Zv O GAL. FROM TANKS: TANK SIZE GAL_ FROM DRUMS VEHICLE TYPE: _ VAC TRUCK TANK TRUCK RAILROAD TANK CAR CHECK COMPATIBLE STORAGE MATERIALS: STEEL _STAINLESS STEEL (316) RUBBER LINED _FIBERGLASS LINED _ OTHER I. SAMPLE STATUS ❑ BULK SOLD TON/YD PER SHIPMENT STORAGE CAPACITY TON/YD VEHICLE TYPE: DUMP TRAILER ROLL OFF BOX INTERMODAL ROLLOFF BOX CUSCO/VACTOR OTHER ..d REPRESENTATIVE SAMPLE HAS BEEN SUPPLIED. ❑ YES ❑ NO SAMPLED BY J. SPECIFIC DISPOSAL RESTRICTIONS OR REQUESTS: SPECIAL WASTE HANDLING REQUIREMENTS: OTHER COMMENTS OR REQUESTS: _ ❑ CONTAINERIZED CONTAINERS/SHIPMENT STORAGE CAPACITY: CONTAINERS CONTAINER TYPE: CUBIC YARD BOX PALLET TOTE TANK DRUM SIZE: CONTAINER MATERIAL: STEEL FIBER PLASTIC OTHER K. BIENNIAL/ANNUAL REPORTING INFORMATION. SIC CODE SOURCE CODE FORM CODE ORIGIN CODE DATE SAMPLED GENERATOR'S CERTIFICATION I hereby certify that all information submitted in this and attached documents Is correct to the best of my knowledge. I also certify that any samples submitted are representative of the actual waste. If Clean Harbors discovers a discrepancy during the approval process, Generator grants Clean Harbors the authority to w amend the profile, as Clean Harbors deems necessary, to reflect the discrepancy. IGNATURE ,NAME (PRINT) Aa%iNT �i1A� S e/6 t_ FOR CLEAN HARBORS USE ONLY CHI REPRESENTATIVE COMPLETING PROFILE: (:HI 102 CLEAN HARBORS COPY TITLE An E 3 10/06/2003 MON 07:40 [TX/RX NO 64441 x(004