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IAU�� Che ico Waste Managemer Inc. G !lly ERATOR'S WASTE PROFILE SHEET EB 3 6 6 4 Profile# (Please care read the instructions before completing this form. Please print in ink or type) Sales# ,rvice Agreement on file? Yes El ❑ Classification: Class I Class II❑ Daily Cover CINon Haz.C2TSDF requested Technology request, ❑Check here if this is a Recertification ❑Check here if a Certificate of Destruction or Disposal is required GENERAL INFORMATION _ 1. GENERATOR NAME: I rA c— Generator USEPA ID: CAL 6 b 1 E 0 $ y5 2. Site Location: "—k^ 57 Bi ling Address- Same: k47y 4 �� 3. Technical ContacUPhonet—,) 4. Alternate Contact/Phone. ��` -SM —/lob Billing Contact/Phone: Fax Number: 9 tf--N— L4 113 Fax Number: PROPERTIES AND COMPOSITION L 5. A. Process Generating Waste: B. Is the waste from a CERCLA or state mandated cleanup?Yes❑ Nox 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: 7. A. Is this a USEPA hazardous waste 40 CFR Part 261)? Yes❑ No B. If D001, D002,D003,D004-DO43 Jo any underlying hazardous constituents U s)apply? Yes❑ No❑ (if yes,attach UHC form) C.Does this waste contain debris(Li;t size and type in chemical composition)? Yes❑ No`y< D.Identify ALL USEPA listed and characteristic waste code numbers(D,F,K,P,U): A) 0�J State Waste Codes: Y I E. Does this waste contain any Class I or Class II ozone depleting substances? ❑Yes(List in chemical composition)"fdo 8. Physical state @ 70°F;A,SolidLiquid❑ Both❑ Gas❑ B. Single LayeA Multilayer❑ C.Free Liquid range J_to _% 9. A.pH:Range to or Not applicableeB.Strong Odor ❑:describe C.Color 10. Liquid Flash Point:<73°F❑ 73-99° ❑ 100-139°F❑ 140-199°F❑ >200°F❑ N.A. CHEMICAL COMPOSITION: List ALL constituents(including halogenated organics and&C's)present in any concentration and forward available analysis. Constituents Range Units CConstituents Range Units TOTAL COMPOSITION MUSTEQUAL 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 Ll 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 CC controls? Yes❑ NoX Volatile organic concentration,if known ppmw. 15. If the waste is subject to the land ban and meets the treatment standards,check here: and supply analytical results. SHIPPING INFORMATION 16. PACKAGING: Bulk Solid❑ Type/Size: Bulk Liquid ❑ ype/Size Drum,�Type/Size SS her 17. SHIPPING FREQUENCY:Units t ., Per: ❑Month Qtr. ❑Year ❑One Time ❑Other SAMPLING INFORMATION 18. A. Sample source(drum,lagoon,pon ,tank,vat,etc.) Date Sampled: -z Sampler's Name/Company: fi'k s% e-- B.Generator's Agent Supervision San pling 19. ❑ No sample required(See instructions) GENERATOR'S CERTIFICATION I hereby certify that all information submitted in his 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 an equivalent method.All relevant information regarding known or suspected hazards in the possession of the generator has been ,dosed.I authorize CWM to obtain a sample f om any waste shipment for purposes of recertification.If this certification is made by a broker,the undersigned signs as authorized ;nt gnhe generator and has nfirmed the i irmation contained in this Profile Sheet from information provided by the generator and additional information as it has determined to _e res ably necessary. Signature Printed (or typed) ame and title Date If the waste profile is approved,Chemical Waste Management,Inc.has the appropriate permits and will accept the waste pursuant to our agreement. CWM Form 6000-DI replaces the following forms: CWM-51,CWM 6000,CWM 50-A-2,CWM 50-B,CWM 6000C AND CWM Form 6000-D. WM101