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WvRg\ Ch mi IWaste l\/ilanagemero Inc. G NERATOR'S WASTE PROFILE SHEET EB 3618 Profile# (Please car fully read the instructions before completing this form.Please print in ink or type) Sales# .ervice Agreement on file? Yes ❑ N LlClassification: Class A 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: t C-' S r A o J, Generator USEPA ID: CAL noo (, 2. Site Location: ^ .t .�0 Billing Address: Same: c.* T-yej c A 1 '?-5-4-0 3. Technical ContacUPhone: P 1W Jto- —`I 4. Alternate Contact/Phone:- t p s -9 S !!oj Billing Contact/Phone: Fax Number: 40iD Fax Number: PROPERTIES AND COMPOSITION 5. A.Process Generating Waste: Ar !A 5 ✓ B. Is the waste from a CERCLA or s to mandated cleanup?Yes❑ No Location Name: C. Is your waste a result of a clean- p action and qualifies for reduced CA BOE Tax? Yes❑ NoK 6. Waste Name: r "rt �� 'CA I e- 7. 7. A. Is this a USEPA hazardous waste(40 CFR Part 261)? Yes❑ NOX B. If D001, D002, D003, D004-DO43 o 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)? YesX No❑ D.Identify ALL USEPA listed and cha cteristic waste code numbers(D,F,K,P,U): QJ G N Z State Waste Codes: I i E. Does this waste contain a4CIasr Class II ozone depleting substances? ❑Yes(List in chemical composition))(No 8. Physical state 70°F;A,Sd❑ Both❑ Gas❑ B.Single Laye Multilayer❑ C. Free Liquid range to9. A.pH:Range toor Not applicable B.Strong Odor ❑:describe C.Color 0. Liquid Flash Point:<73°F❑ 100-139°F❑ 140-199°F❑ >200°F❑ N.A.CHEMICAL COMPOSITIONnstituents(including halogenated organics and HC's)present in any concentration and forward available analysis. Constituents Range Units Constituents Range Units #7s _ A6 TOTAL COMPOSITION MUST EQUA OR EXCEED 100% 12. OTHER: PCB's,if yes,concentration(dry weight) ppm, PCB's regulated by 40 CFR 761 ❑ Pyrophoric❑ Explosive❑ Radioactive❑ Water Reactive❑ Shock Sensitive Oxidizer❑ Carcinogen❑ Infectious❑ Other 13. If Benzene is present,concentration A) A ppm. Is the waste subject to the Benzene Waste Operation NESHAP? Yes❑ No❑ Unknown❑ 14. Is the waste subject to RCRA subpart C controls? Yes❑ No Volatile organic concentration,if known ppmw. 15. If the waste is subject to the land ban nd meets the treatment standards,check here:_and supply analytical results. SHIPPING INFORMATION 16. PACKAGING: Bulk Solid❑ Type/Siz : Bulk Liquid ❑Type/Size Drumtype/Size 5S-G4-1 Other 17. SHIPPING FREQUENCY: Units f-j Per: ❑Month ❑Qtr. ❑Year One Time ,❑`Other SAMPLING INFORMATION 18. A.Sample source(drum,lagoon,pond tank,vat,etc.) r Date Sampled: 6 1 -1- -i Sampler's Name/Company: I)F L p,rr�s s�'• B.Generator's Agent Supervision Sam ling 19. ❑ No sample required(See instructions) GENERATOR'S CERTIFICATION I hereby certify that all information submitted in t 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 sclosed.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 ent o e 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 re on bly necessary. z ff 6�1- Signature Printed(or typed)name And title ate If the waste profile is approved,Chemic I Waste Management,Inc.has the appropriate permits and will accept the waste pursuant to our agreement. CV/M Form 6000-DI replaces the follow! g forms: CWM-51,CWM 6000,CWM 50-A-2,CWM 50-B,CWM 6000C AND CWM Form 6000-D. WM101