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Oct, 06 03 07:45a PA' Environmental tiw (F" -a) 233-4284 P.7 MW CleanNa'rsrboProfile Number C H 2 2 2 2 2 2 Page 3 of 3 No ,ENVIRONMENTAL SURVICES. INC. F. REGULATORY STATUS Y N ❑ 0 USEPA HAZARDOUS WASTE? (IF Yes List codes.) a. ❑ DO ANY GENERATOR STATE WASTE CODES APPLY? IF YES, LIST STATE CODES S Z LIST ANY FEDERAL OR STATE WASTE CODES WHICH MAY VARY FROM SHIPMENT TO SHIPMENT: WILL THE DECISION TO VARY THESE WASTE CODES BE BASED ON ❑ KNOWLEDGE OR O TESTING (check one). ' IF KNOWLEDGE, DESCRIBE BASIS OF KNOWLEDGE: r ❑ 1� IS THIS WASTE PROHIBITED FROM LAND DISPOSAL WITHOUT FURTHER TREATMENT PER 40 CFR PART 268? THIS WASTE IS A: ❑ WASTEWATER ANON 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 - am 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? ❑ �b 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 >_ 500 PPM? ❑ DOES THIS WASTE CONTAIN GREATER THAN 20 % OF ORGANIC CONSTITUENTS WITH A VAPOR PRESSURE >_ .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 shipping names that may be used. Attach additional page if necessary. yD.O.T. SHIPPING NAME �2N �ZG�l4 l-i-f�zAl�.-�o� (,t2p,sT� �e_l� DOT HAZARD CLASS: JN/NA if PACKING GROUP (Circle 1) I II III HAZARD ZONE (Circle 1) A B C D MILL THIS SHIPPING NAME VARY? ❑ Y ❑ N IF YES, WILL ASSIGNMENT OF PROPER SHIPPING NAME BE BASED ON ❑ KNOWLEDGE OR 6010 TESTING? (check one) IF KNOWLEDGE, DESCRIBE BASIS OF KNOWLEDGE: N. TRANSPORTATION REQUIREMENTS ESTIMATED SHIPMENT FREQUENCY: ❑ ONE TIME ❑ WEEKLY CJ SEMI-MONTHLY ❑ MONTHLY ❑ QUARTERLY ❑ OTHER r ❑ BULK LIQUID GALLONS/SHIPMENT: GAL. ft+ 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 NF�BULK SOLD 20 TO YD PER SHIPM�.tVT STORAGE CAPA Z TON1II(.W VEHICLE TYPE: DUMP TRAILER ROLL OFF BOX INTERMODAL ROLLOFF BOX CUSCO/VACTOR OTHER ❑ CONTAINERIZED CONTAINERS/SHIPMENT STORAGE CAPACITY: CONTAINERS CONTAINER TYPE: CUBIC YARD BOX PALLET TOTE TANK DRUM SIZE: _. CONTAINER MATERIAL: STEEL FIBER PLASTIC OTHER SAMPLE STATUS REPRESENTATIVE SAMPLE HAS BEEN SUPPLIED. ❑ YES ❑ NO SAMPLED BY DATE SAMPLED_ - J. SPECIFIC DISPOSAL RESTRICTIONS OR REQUESTS: SPECIAL WASTE HANDLING REQUIREMENTS: — OTHER COMMENTS OR REQUESTS: K. BIENNIAL/ANNUAL REPORTING INFORMATION. SIC CODE SOURCE CODE FORM CODE ORIGIN CODE sm GENERATOR'S CERTIFICATION I hereby certify that all inforrnatlon submitted in this and attached documents is correct to the best of my knowledge. I also certify that any samples submitted 3 representative of the actual waste. If Clean Harbors discovers a discrepancy during the approval process, Generator grants Clean Harbors the authority to lend the profile, as CI an Harbors deems necessary, to reflect the discrepancy. AUT}4oORIZ IG U E NAME (PRINT) TITLE DATE 7 / v MR CLEAN yARBORS USE ONLY CHI REPRESENTATIVE COMPLETING PROFILE: :HI tuz CLEAN HARBORS COPY y 10/06/2003 MON 07:40 (TX/RX NO 64441 Z 007