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WV2�\ Che is ; WasteManagemer Inc. G !lly ERATOR'SWASTE PROFILE SHEET EB 3665 (Please care read the instructions before completing this form.Please print in ink or type) Profile# Sales# �__arvice Agreement on file? Yes ❑ N ❑ 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: z "s C Generator USEPA ID: (flA L c)0n 16,0 5P�/ 2. Site Location: io .3,-j- 4-P a Si Billing Addres Asame: 3. Technical Contact/Phone: - 4 .pL-4`l I 4. Alternate Contact/Phone: A r:na of Billing Contact/Phone: Fax Number: 6 -' 01 0 Fax Number: PROPERTIES AND COMPOSITIOJorst 5. A. Process Generating Waste: f- L; 6. Is the waste from a CERCLmandated cleanup?Yes❑Nol Location Name: C. Is your waste a result of a cction and ualifies for reduce CA BOE Tax? Yes❑ No❑ 6. Waste Name: 7. A. Is this a USEPA hazardous waste 0 CFR Part 261)'. Yes❑ NoX B. If D001, D002, D003,D004-DO43 o any underlying hazardous constituents(UHC's)apply? Yes C3 No❑ (if yes,attach UHC form) C.Does this waste contain debris(Li size and type in chemical composition)? Yes❑ No)< D.Identify ALL USEPA listed and char cteristic waste code numbers(D,F,K,P,U): State Waste Codes: E. Does this waste contain any Class or Class II ozone depleting substances? ❑Yes(List in chemical composition) ❑No 8. Physical state @ 70°F;A,Solid( Li uid❑ Both❑ Gas❑ B.Single LayerrX Multilayer Ll C.Free Liquid range to Q_% 9. A.pH:Range to or Not applicableva Strong Odor ❑:describe C.Color Liquid Flash Point:<73°F❑ 73-99° ❑ 100-139°F❑ 14 -199°F❑ >200°F❑ N.A's) CHEMICAL COMPOSITION: List ALL onstituents(including halogenated organics and present in any concentration and forward available analysis. Constituents Range Units Constituents Range Units 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 Ell Water Reactive❑ Shock Sensitive❑ Oxidizer❑ Carcinogen❑ Infectious❑ Other 13. If Benzene is present,concentration pm.Is the waste subject to the Benzene Waste Operation NESHAP? Yes❑ No❑ Unknown❑ 14. Is the waste subject to RCRA subpart C controls? Yes❑ N�Volatile organic concentration,if known pprnw• 15. If the waste is subject to the land ban d meets the treatment standards,check here: and supply analytical results. SHIPPING INFORMATION 16. PACKAGING: Bulk Solid❑ Type/Size Bulk Liquid ❑Type/Size DrumType/Sized Other 17. SHIPPING FREQUENCY: Units ` hi,—-- Per: ❑Month "ZOtr. ❑Year ❑One Time ❑Other SAMPLING INFORMATION 18. A.Sample source(drum,lagoon,pond tank,vat,etc.) Dato Sampled: ?,I 1`3 Samplur's Name/Company: lc -* -?.•< �� B.Generator's Agent Supervision Sam fling 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 1,�fined 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 ;lased.I authorize CWM to obtain a sample fr many waste shipment for purposes of recertification.If this certification is made by a broker,the undersigned signs as authorized d h ant of the generator anas onfirmed the info ation contained in this Profile Sheet from information provided by the generator and additional information as it has determined to �—oe naso Iy necessary. ignature Printed(or type name 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 followi g forms: CWM-51,CWM 6000,CWM 50-A-2,CWM 50-131,CWM 6000C AND CWM Form 6000-D. WM101