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Ch mi IWaste Managemerro Inc. G NERATOR S WASTE PROFILE SHEET EB 3617 Profile# } (Please car fully read the instructions before completing this form. Please print in ink or type) Sales# a(vice Agreement on file? Yes ❑ o Cl Classification: Class X Class II❑ Daily Cover❑ Non Haz.❑ TSDF requested Technology requested ❑Check here if this is a Recertification ❑Check here if a Certificate of Destruction or Disposal is required GENERAL INFORMATION 1. GENERATOR NAME: 1<4t-v F-P gac v<_ `,vcX T-r+C Generator USEPA ID: C'y9 L OC)o 16 o ys 2. Site Location: — I o _ 7 Billing Address:\Y"zame: D ` 3. Technical Contact/Phone: /i,—!f� 4. Alternate Contact/Phone: k.r w« c)ct-ci lik—P I Billing Contact/Phone: Fax Number: qu IQ Fax Number: PROPERTIES AND COMPOSITION 5. A.Process Generating Waste: •+ �'% �— '.? B. Is the waste from a CERCLA or sate mandated cleanup?Yes❑ NoX Location Name: C. Is your waste a result of a clean-,p action and qualifies for reduced CA BOE Tax? Yes❑ NdX 6. Waste Name: f 7. A. Is this a USEPA hazar ous waste(40 CFR Part 61)? Yes❑ No4 B. If D001,D002, D003, D004-DO43 do any underlying hazardous constituents(UHC's)apply? Yes❑ No❑ (if yes,attach UHC form) C. Does this waste contain debris(Li t size and type in chemical composition)? Yes❑ NoX D.Identify ALL USEPA listed and cha cteristic waste code numbers(D,F,K,P,U): AJ u A,z State Waste Codes: E. Does this waste contain a4Clas Class II ozone depleting substances? ❑Yes(List in chemical compositionXNo 8. Physical state @ 70°F;A,Sod❑ Both❑ Gas❑ B.Single LayeXr Multilayer❑ C. Free Liquid range� to � % 9. A.pH:Range toor Not applicable B.Strong Odor ❑:describe C.Color 10. Liquid Flash Point:<73°F❑ 100-139°F❑ 14 -199°F❑ >200°F❑ N.A�1. CHEMICAL COMPOSITIONnstituents(including halogenated organics and UHC's)present in any concentration and forward available analysis. Constituents Range Units Constituents Range Units „ casto _� S-A it3 b Fl TOTAL COMPOSITION MUST EQUA OR EXCEED 100% 12. OTHER: PCB's, if yes,concentration(dry weight) ppm,PCB's regulated by 40 CFR 761 CIPyrophoric❑ Explosive❑ Radioactive❑ Water Reactive❑ Shock Sensitive Oxidizer CJ Carcinogen:3 Infectious L1 Other 13. If Benzene is present,concentration ppm. Is the waste subject to the Benzene Waste Operation NESHAP? Yes El No Ll Unknown❑ 14. Is the waste subject to RCRA subpart C controls? Yes L1N Volatile organic concentration,if known ppmw. 15. If the waste is subject to the land ban nd meets the treatme t standards,check here: and supply analytical results. SHIPPING INFORMATION 16, PACKAGING: Bulk Solid❑ Type/Size: Bulk Liquid ❑Type/Size Drum/XType/Size (Other 17. SHIPPING FREQUENCY: Units b!,. Per ❑Month ❑Qtr. ❑Year ne Time ❑Other SAMPLING INFORMATION 18. A.Sample source(drum,lagoon,pon ,tank,vat,etc.) 0 M Date Sampled: ��'1 Sampler's Name/Company: =I an ks / key S:.h e B.Generator's Agent Supervision Sa pling 19. ❑ No sample required(See instructions) GENERATOR'S CERTIFICATION I hereby certify that all information submitted in is and all attached documents contains true and accurate descriptions of this waste.Any sample submitted is representative as defined in 40 CFR 261 -Appendix 1 or by using n equivalent method.All relevant information regarding known or suspected hazards in the possession of the generator has been lisclosed.I authorize CWM to obtain a sample fr m any waste shipment for purposes of recertification.If this certification is made by a broker,the undersigned signs as authorized lent of the generator and has confirmed the info mation contained in this Profile Sheet from information provided by the generator and additional information as it has determined to ,e resonably necessary. -maks VDc,�Ci Signature Printed(or typed)nam and title Da e If the waste profile is approved,Chem icI Waste Management,Inc.has the appropriate permits and will accept the waste pursuant to our agreement. CWM Form 6000-10I replaces the followi g forms: CWM-51,CWM 6000,CWM 50-A-2,CWM 50-B,CWM 6000C AND CWM Form 6000-D. WM101