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WORLD OIL <br /> RECYCLING(,: <br /> WORLD OIL RECYCLING'S LABORATORY IS CERTIFIED BY THE CALIFORNIA,DEPARTMENT OF HEALTH <br /> SERVICES ENVIRONMENTAL LABORATORY ACCREDITAT iON PROGRAM ( F_LAP) CERT. #2037 <br /> GENERATOR 'SWASTE PROFILE VVORKSHEET <br /> GENERAT'OR'S INFORMATION <br /> A. GENERATOR'S NAME RevChem Stockton B EPA ID# CAR000295691 <br /> C. GENERATOR'S ADDRESS 4807 S.Airport Way D PHONE P09) 419-3090 <br /> E. CITY STATE, ZIP Stockton, CA 95206 <br /> F. GENERATOR CONTACT Kaytee Heiner G TITLE Technical Contact <br /> H. CUSTOMER NAME Univar USA Inc. I. PHONE ( ) <br /> J. TRANSPORTER NAME Univar K PHONE (805 535-5053 <br /> L. TRANSPORTER EPA ID# CAR000047696 M. CONTACT Steven Concha <br /> A. NAME OF WASTE Antifreeze <br /> B. CALIFORNIA HAZARDOUS WASTE CODE NO. 343 <br /> C. EPA HAZARDOUS WASTE CODE NO. N/A <br /> D. DESCRIBE PROCESS GENERATING WASTE spent Antifreeze from Maintenance Change Out <br /> IS THIS WASTE REGULATED UNDER THE BENZENE NESHAP RULES? F-1 yes _ ✓Q_no <br /> IF YES, IS BENZENE WASTE FROM A CHEMICAL MANUFACTURING, COKE <br /> BY-PRODUCT RECOVERY, OR PETROLEUM REFINERY PROCESS? 0 yes _ ✓E no <br /> E. DOES THIS WASTE CONTAIN PCB'S? F-1_._yes G71 no <br /> F. DOES THIS WASTE CONTAIN DIOXIN? (F020-FO28) �_yes J _ no <br /> G. DOES THIS WASTE CONTAIN SULFIDES OR CYANIDES? yes _0— no <br /> H. DOES THIS WASTE CONTAIN PESTICIDES OR HERBICIDES? F-1_yes _Q_no <br /> (IF YES, IDENTIFY IN ITEMS A OR D ABOVE.) <br /> I. DOES THIS WASTE CONTAIN SOLVENTS? ❑_ yes �._ no <br /> (IF YES, IDENTIFY IN ITEMS A OR D ABOVE.) <br /> J. DOES THIS WASTE CONTAIN PLATING WASTE? ❑ yes �._ no <br /> K. HAS THIS WASTE BEEN MIXED WITH RCRA LISTED WASTE? <br /> (F, K, U OR P EPA WASTE CODES) F_yes _I—L] no <br /> L. IF YOU HAVE MSDS FOR COMPONENTS IN THIS WASTE, <br /> PLEASE ATTACH.......................................................................................MSDS ATTACHED ❑ <br /> M. IF YOU HAVE CURRENT ANALYSIS OF THIS WASTE, <br /> PLEASE ATTACH .....................--------------------- .......................CHEMICAL ANALYSIS ATTACHED ❑ <br /> N. PACKAGING / VOLUME ❑ BULK LIQUID 0 DRUMS ❑ OTHER _ ❑ AMOUNT <br /> ❑✓ GALLONS ❑ LBS. ❑ CUBIC YARDS PER: ❑DAY ❑MONTH ❑QUARTER ❑✓ YEAR <br /> GENERATOR'S CERTIFICATION <br /> I HEREBY CERTIFY THAT THE INFORMATION PROVIDED ON THIS DOCUMENT,IS TRUE AND ACCURATE,AND NO INTENTIONAL MIS- <br /> REPRESENTATION HAS BEEN COMMITTED BY ANYONE. I FURTHER CERTIFY THAT ANY SAMPLE(S) PROVIDED WITH THIS WASTE <br /> PROFILE WERE TAKEN AND PRESERVED IN ACCORDANCE WITH 40 CFR 261,APPENDIX 1 AND ARE ACCURATE AND REPRESEW <br /> TATIVE OF MY ACTUAL WAST E1. 1 GREE TO NOTIFY WORLD OIL RECYCLING SHOULD THIS WASTE STREAM <br /> CHANGE IN ANY WAY. <br /> AUTHORIZED SIGNATU DATE / !Lam_ <br /> PRINT NAME AND TITLE ^�11i <br /> FORM NO.1001 HEV.4-15-08,5-25-10,6-1-17 <br />