Laserfiche WebLink
Profile Number: <br /> Expiration Date: <br /> WASTE PROFILE SHEET <br /> TERMS & CONDITIONS <br /> Service Agreement on File? Profile Addendum Attached? <br /> ❑Yes ❑ No This form is Ito be used to comply with the requirements of governmental waste screening criteria. ❑Yes ❑ No <br /> Generator <br /> 1. Generator/Site Name: 2, SIC Code: <br /> 3. Site Address: .3 1 L- 5 4. Site City: STo c <br /> 5. Site State: <::!A 7.Z p Code: gS r 6. Site Country: S ff <br /> 8. Generator USEPA/Federal ID#: 9. Site Phone: U;- 9 S ^ <br /> 10. Customer Name: 11. Customer Phone: :fid rr - y f SP /f C) I <br /> V <br /> 12. Customer Contact: - L nr 1c.f 13. Customer FAX: ��c%- �}�Y- L I O <br /> Bi,Waste Stream and Billing Information <br /> 1. Waste Description,Category: " :N< L.S 3. Billing Address: <br /> 2. State Waste Code: A-) A <br /> 4. Process Generating Waste: <br /> 5. Transporter/Transfer Station: 6.Shipping Method: ! �� <br /> 7. Estimated Quantity(Weight&Vol.): - a r tis per ❑ Job Year ❑ Other <br /> 8. Delivery Date(s): <br /> 9. Personal Protective Equipment Re uirements: /V G•'.+ e- <br /> 10. Is t is S Dept. of Transportation(USDOT)Hazardous Material? 11. Reportable Quantity: <br /> ❑ Yes No (If no,skip 10,11 and 12) <br /> ,2. Hazard Class/I.D.#: 13. Shipping Name: <br /> ❑ Check if additional information is a ched. Indicate the number of attached pages: S R"_0 A-,../}1y 5 <br /> Generator's Certification(P acc,�pr a-e <br /> Yes No <br /> 1. Is the waste represented by this wa to profile sheet a"Hazardous Waste"as defined by USEPA, ❑ <br /> Canadian,Mexican,State,or Provin ial regulation? <br /> 2. Does the waste represented by this aste profile sheet contain regulated radioactive material or ❑ <br /> regulated concentrations of Polychl rinated Biphenyls(PCBs)? <br /> 3. Does this waste profile sheet and all attachments contain true and accurate descriptions of the ❑ <br /> waste material? <br /> 4. Has all relevant information within thpossession of the Generator and Customer regarding known ❑ <br /> or suspected hazards pertaining to t e waste been disclosed to the Contractor? <br /> 5. Is the analytical data attached heret derived from testing a representative sample in accordance X ❑ ❑ N/A <br /> with 40 CFR 261.20(c)or equivalent rules? <br /> 6. Will all changes that occur in the ch racter of the waste be identified by the Generator and X ❑ <br /> disclosed to the Contractor prior to p oviding the waste to the Contractor? <br /> D-tWM Management's Decision <br /> 1. Management Method: <br /> 2. Designated Facility: 3. Hours of acceptance: ❑N/A <br /> 4. Precautions,Special Handling Proce lures,or Limitations on Approval: <br /> Generic Approval: ❑Yes ❑No Special Waste Decision: ❑Approved ❑Disapproved <br /> Sales Person: Date: Technical Manager: Date: <br /> GENERATOR AND CUSTO ER MUST READ AND SIGN REVERSE HEREOF INITIAL <br /> INITIAL <br />