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' f <br /> REPUBLJC EXPRESS WASTE PROFILE <br /> SERVICES <br /> Waste Profile# <br /> Requested Disposal Facility: 4204 Forward Inc. CA <br /> Saveable fill in form. Restricted printing until all required(yellow)fields are completed <br /> 1. Generator Information Sales Rep#. <br /> Generator Name: CRM Co LLC <br /> Generator Site Address: 1404 S. Fresno Ave <br /> City: Stockton County: San Joaquin State: California Zip: 95382 <br /> State ID/Reg No: n/a State Approval/Waste Code: n/a (if applicable) NAICS#. n/a <br /> Generator Mailing Address (if different): 1404 S. Fresno Ave <br /> City: Stockton I County: Stockton State: California Zip: 95382 <br /> Generator Contact Name: Steve Krauss IEmail: skrauss@crmrubber.com <br /> Phone Number: (916)584-5158 Ext: Fax Number: <br /> 11. Billing Information <br /> Bill To: W.C. Maloney Inc Contact Name: Curt Maloney <br /> Billing Address: PO Box 30326 1Email: curt@wcmaloney.com <br /> City: Stockton State: Ca. Zip: 95213 Phone: (209)942-1129 <br /> Ill. Waste Stream Information <br /> Name of Waste: ❑ Diesel Fuel 0 Weathered Wood ❑ Friable Asbestos <br /> (Petroleum ❑ Home Heating Fuel#1-6 ❑ RCRA Empty Containers ❑ Non Friable Asbestos <br /> products-applies Kerosene <br /> only tocontammated ❑ Treated Medical Waste ❑ Cured Asphalt <br /> media and debris). ❑ Aviation Fuel ❑ Animal Carcass(non infectious) ❑ Tires <br /> [] Hydraulic Fluid ❑ Plant Trash ❑ Food Products <br /> ❑ Unleaded Gasoline(UST Corrective Action) ❑ Meth Contaminated Debris (Including Animal Food) <br /> Process Generating Waste: Rail Road Ties <br /> Method of Shipment: Q BULK []DRUM ❑ BAGGED ❑OTHER: <br /> Estimated Annual Volume: 20 Cubic Yards <br /> Frequency: ®ONE TIME []ONGOING <br /> IV. Certification <br /> I hereby certify that to the best of my knowledge and belief,the information contained herein is a true and accurate description of the <br /> j waste material being offered for disposal, I further certify that by utilizing this profile,. neither myself nor any other employee of the <br /> !company will deliver for disposal or attempt to deliver for disposal any waste which is classified as toxic waste,hazardous waste or <br /> infectious waste or any other waste material this facility is prohibited from accepting by law. Our company hereby agrees to fully <br /> indemnify this disposal facility against any damages resulting from this certification being inaccurate or untrue.I further certify that the <br /> company has not altered the form or content of this profile sheet as provided by Republic Services,Inc. <br /> Steve Krauss CRM Co LLC <br /> Authonz d Re r entative Name[Title(Type or Print) Company Name <br /> 9-28-17 <br /> t epresentat a gnature Date <br /> REV 2 ORepublic Services, April 2013 <br />