COMPLIANCE INFO_PRE 2019 - Laserfiche WebLink

Home Browse Search

IAU&� Che ill Waste Managemer Inc. G NERATOR'S WASTE PROFILE SHEET EB :3 6 6 il Profile# (Please care ully read the instructions before completing this form.Please print in ink or type) Sales# _arvice Agreement on file? Yes ❑ N LlClassification: Class K 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: �c _ Generator USEPA ID: CALe)no I rdy� 2. Site Location: Ellc ,, 4o 5— Billing AddresASame: o C k 3. Technical Contact/Phone: h • L S o� - ''��- I D 1 4. Alternate Contact/Phone: loc - 1/a Billing Contact/Phone: Fax Number: 90 4- Ei Fax Number: PROPERTIES AND COMPOSITION 5. A.Process Generating Waste: s��: w c� ,W S �, ._ i�e S B. Is the waste from a CERCLA or st to mandated cleanup?Yes❑ No>K 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: 5w cC - t� 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❑ NcK D.Identify ALL USEPA listed and char cteristic waste code numbers(D,F,K,P,U): N- v -e_ State Waste Codes: t E. Does this waste contain any Clss I or Class II ozone depleting substances? Yes(List in chemical composition)XNo 8. Physical state @ 70°F;A,Solic g L quid❑ Both❑ Gas❑ B.Single Layel/ Multilayer❑ C.Free Liquid range�to Q_% 9. A.pH:Range to or Not applicablB.Strong Odor Cl:describe C.Color �. Liquid Flash Point:<73°F Cl 73-99° ❑ 100-139°F❑ 1 -199°F❑ >200°F❑ N.A. CHEMICAL COMPOSITION:List ALL constituents(including halogenated organics and UH(N)present in any concentration and forward available analysis. Constituents Range Units Constituents Range Units cls i TOTAL COMPOSITION MUST EQUA OR EXCEED 100% 12. OTHER: PCB's,if yes,concentration dry weight) ppm, PCB's regulated by 40 CFR 761 LIPyrophoric L] Explosive❑ Radioactive C3Water Reactive C3 Shock Sensitive Oxidizer❑ Carcinogen❑ Infectious❑ Other 13. If Benzene is present,concentration /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 C3NOX 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 ❑T pe/Size Drumype/Size G f Other 17. SHIPPING FREQUENCY:Units ^ Per: ❑Month Qtr. ❑Year ❑One Time 'O ther SAMPLING INFORMATION 18. A.Sample source(drum,lagoon, and tank,vat,etc.) r^� Dato Sampled: w . } Samplor's Namo/Company:n L( 'wti� �� 4 e 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 closed.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 ;nt of the generator and h confirmed the info ation contained in this Profile Sheet from information provided by the generator and additional information as it has determined to ,e re nably necessary. Signature Printed (or typed)94me and title D to 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 6000-13I replaces the followi g forms: CWM-51,CWM 6000,CWM 50-A-2,CWM 50-B,CWM 6000C AND CWM Form 6000-D. WM101