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WVR�\ Che icoWaste Managemer Inc. G NERATOR S WASTE PROFILE SHEET EB 3662 Profile# (Please care ally read the instructions before completing this form.Please print in ink or type) i Sales# rvice Agreement on file? Yes ❑ N ❑ Classification: Class 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: r N c' +0,A,, � 7,J. G rator USEPA ID: C A L c)©G ICO*yS 2. Site Location: i �t r o ; Billing Address Same: T'o c!L 3. Technical Contact/Phone: f k `1-`%'�� '1 to 4. Alternate Contact/Phote: iW Billing Contact/Phone: Fax Number: 9, - (0 qD 10 Fax Number: PROPERTIES AND COMPOSITION 5. A. Process Generating Waste: Fr +� �- •, B. Is the waste from a CERCLA or st to mandated cleanup?Yes❑ No❑ Location Name: C.Is your waste a result of a clean-u action and qualifies for reduced CA BOE Tax? Yes❑ No❑ 6. Waste Name: r^ c.^ < < N e. "t-tic 7. A. Is this a USEPA hazardous waste 40 CFR Part 261)? Yes❑ No 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)? Yes❑ NoA D.Identify ALL USEPA listed and char cteristic waste code numbers(D,F,K.P,U): /V 0,-, c State Waste Codes: IFS 1 E. Does this waste contain any Class or Class II ozone depleting substances? ❑Yes(List in chemical composition)X No 8. Physical state @ 70°F;A,Solid Li uid LlBoth C3Gas Z] B.Single Laye Multilayer C3 C.Free Liquid range to 9. A.pH:Range to or Not applicable B.Strong Odor LI:describe C.Color 10. Liquid Flash Point:<73°F❑ 73-99° CJ100-139°F❑ 14 -199°F❑ >200°F❑ N.A�H's) CHEMICAL COMPOSITION:List ALL onstituents(including halogenated organics and present in any concentration and forward available analysis. Constituents Range Units � Constituents Range Units ri TOTAL COMPOSITION MUST EQUA OR EXCEED 100% 12. OTHER: PCB's,if yes,concentration ry 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 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 a d meets the treatment standards,check here: and supply analytical results. SHIPPING INFORMATION ,- 16. PACKAGING: Bulk Solid❑ Type/Size Bulk Liquid ❑Type/Size Drum Type/Size -")S 6.'41 Other 17. SHIPPING FREQUENCY: Units r ^w Per: ❑Month NQtr. ❑Year ❑One Time ❑Other SAMPLING INFORMATION 18. A.Sample source(drum,lagoon,pond,tank,vat,etc.) Date Sampled: J 10 t Sampler's Name/Company: S /c fiS% • t B.Generator's Agent Supervision Sam liling 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 a equivalent method.All relevant information regarding known or suspected hazards in the possession of the generator has been 'isdosed.I authorize CWM to obtain sample fro any waste shipment for purposes of recertification. If this certification is made by a broker,the undersigned signs as authorized I` ""0f a generator and has cont med the i r ation contained in this Profile Sheet from information provided by the generator and additional information as it has determined to ,ea on bly necessary. Signature Printed(or typed)Kame and title Date If the waste profile is approved,Chemica Waste Management,Inc.has the appropriate permits and will accept the waste pursuant to our agreement. CWM Form 6000-DI replaces the followin forms: CWM-51,CWM 6000,CWM 50-A-2,CWM 50-B,CWM 6000C AND CWM Form 6000-D. WM101